Shanderlyne Worthy
Columbia,SC
Summary
Detail-oriented healthcare support professional experienced in prior authorization, utilization management, and pharmacy benefit workflows. Manage communications with members, providers, and pharmacies while ensuring accurate documentation and HIPAA compliance. Proven ability to support timely resolutions and navigate clinical review queues, enhancing service delivery in fast-paced environments.
Overview
22
22
years of professional experience
Work History
Interim Clinical Technician SR - Med D
Prime Therapeutics
Eagan, Minnesota
09.2026 - Current
- Executed clinical tasks within utilization management workflows, meeting service standards to support operational efficiency.
- Supported Prime Therapeutics clinical review queues for pharmacy benefit requests.
- Provide complete and relevant clinical information related to UM requests to Pharmacists and Physicians to support clinical decision‑making, peer review discussions, and independent review determinations
- Communicated with members, providers, and pharmacies in a clear, professional manner.
- Supported internal reviewers by delivering process guidance and addressing case-specific questions and escalations, enhancing review accuracy.
- Respond to escalated calls from the Contact Center and providers, coordinating accurate information, external appeal considerations, and appropriate resolutions while ensuring thorough documentation to support correct approvals or denials
- Ensured HIPAA compliance while managing sensitive health records to protect patient privacy.
- Entered member information and case notes into clinical systems.
Clinical Operations Technician
Prime Therapeutics
Eagan, Minnesota
12.2023 - Current
- Medicare Department (NJ Clients)
- Communicated with healthcare providers to gather necessary information, resolve issues, and facilitate timely prior authorization requests.
- Developed and updated policies and procedures to ensure compliance with HIPAA, benefits administration, and regulatory guidelines.
- Supported Medicare D clients to improve service delivery and client satisfaction.
- Outbound calls (Outreach) to doctors and members.
- Collaborated effectively with team members to achieve common goals.
- Utilized critical thinking to analyze complex problems.
- Communicate through Microsoft Teams.
Customer Service Representative
SYKES
Sumter, SC
08.2021 - 02.2023
- Answered a constant flow of customer calls with minimal wait times.
- Responded to customer calls promptly, minimizing on-hold wait times.
- Enhanced customer satisfaction through proactive strategies addressing needs and resolving concerns.
- Provided tailored advice and assistance to customers, ensuring special needs were met.
- Developed community reputation through commitment to customer satisfaction and strong client relationships.
- Used a company troubleshooting resolution tree to evaluate technical problems and find appropriate solutions.
- Responded proactively and positively to rapid change.
Customer Service Representative
Afni
Columbia, SC
02.2020 - 05.2020
- Handled high volume of customer calls efficiently at the call center.
- Responded to customer telephone calls promptly, minimizing on-hold wait times.
- Provided tailored advice and assistance to customers, focusing on individual needs and preferences.
- Enhanced customer satisfaction by implementing proactive strategies to address needs and resolve concerns.
CNA/ Central Supply Coordinator
Lifecare Center Of Columbia
Columbia, SC
08.2004 - 02.2020
- Oversaw daily administrative and operational functions for Number-bed facility, guiding and leading over Number employees across more than Number departments.
- Developed and updated policies and procedures to ensure compliance with HIPAA, benefits administration, and general liability regulations.
- Ensured patient medical information confidentiality through effective communication.
Education
Associate Of Applied Science - Medical Assisting
South University
Savannah, GA09-2017
Skills
- Utilization management
- Prior authorization
- Clinical documentation
- Medical Terminology Knowledge
- Clinical Analysis
- Documentation
- Pharmacy benefits
- Microsoft Excel
- Microsoft Word
- Microsoft Teams
- Call Center Operations
- Customer Relations
- Problem-Solving Ability
- Attention to detail
- Policy and Procedure Adherence
- Multitasking
- Team collaboration
- Professional communication
- Calm under pressure
- Stocking and Replenishing
Timeline
Interim Clinical Technician SR - Med D
Prime Therapeutics
09.2026 - Current
Clinical Operations Technician
Prime Therapeutics
12.2023 - Current
Customer Service Representative
SYKES
08.2021 - 02.2023
Customer Service Representative
Afni
02.2020 - 05.2020
CNA/ Central Supply Coordinator
Lifecare Center Of Columbia
08.2004 - 02.2020
Associate Of Applied Science - Medical Assisting
South University