Shandreka Sims
Chesapeake,VA
Summary
Experienced Network Data Specialist Lead with a proven track record of success in high-pressure, deadline-oriented health services environments. Skilled in management, analysis, data management, and claims processing. Strong problem-solving abilities, a commitment to learning, and excellent communication skills. Committed to team success and achieving positive results. Ready to embrace new challenges and advance organizational objectives with dedication and enthusiasm.
Overview
15
15
years of professional experience
Work History
Network Data Specialist Lead
Anthem Inc.
01.2021 - Current
- Support and manage the External/Pended Claims team by running daily queries in SQL and maintaining the workload assignments
- Collaborate, improve and integrate processes on claims resolutions during meetings.
- Consistently meet deadlines and deliver high-quality work, demonstrating a strong commitment to excellence in data management.
- Expertly research provider records with accuracy while providing timely maintenance of critical provider information on claims and provider databases
- Meticulously manage all claim markets including but not limited to MA Blue using analytical and problem-solving skills to resolve complex claim issues
- Adept in analysis, application, data management, claims processing and management.
- As an SME (Subject Matter Expert), assist peers with questions regarding policies and procedures and claims issue resolution
- Efficiently train new hires and less experienced associates on the team to ensure compliance across the department
- Coordinate with the Health Plan daily on numerous special requests to ensure that all validation rules are followed to ensure timely adjudication of claims
- Identify and analyze trends and root cause analysis of claims processing errors related to incorrect provider data
- Create and manage the job training aids for numerous processes across the team
Network Data Specialist Sr.
Anthem Inc.
01.2018 - 01.2021
- Consistently met deadlines and delivered high-quality work, demonstrating a strong commitment to excellence in data management.
- Ensured provider data was the same across multiple claims systems and the application of business rules as they applied to each database
- Validated the data to be housed on provider databases and ensured adherence to business and system requirements of customers as it pertained to contracting, network management and credentialing
- Worked with the Health Plan daily on numerous special requests to ensure that all validation rules were followed to ensure timely payment of claims
- Conducted research and analysis of complex data quality issues and worked to resolve them
- Identified trends and root cause analysis of claims processing errors related to incorrect provider data and resolved issues
- Supported and maintained provider networks through communication with provider organizations, credentialing, and health plan associates
Network Data Specialist II
Anthem Inc.
01.2014 - 01.2018
- Provided claims support by analyzing, researching, and investigating claims in NetworX
- Conducted research of claims to identify trends and root cause analysis of claims adjudication errors and recommended improvements and training to internal departmental leadership
- Utilized strong interpersonal skills to train, mentor and support more junior associates as a Subject Matter Expert
- Worked with other departments to resolve provider issues
- Provided telephonic assistance to members, providers, billing agencies and/or prospective members for assigned products
- Assisted with benefit and eligibility explanations, claim issues, network changes, customer service issues and/or terminations
- Resolved complex or escalated issues of caller by thoroughly researching the cause of the error
- Established and maintained a positive working relationship with medical providers, facilities, members, and internal customers to promote quality service
Provider Service Representative
Anthem Inc.
01.2011 - 01.2014
- Streamlined operations by managing a high volume of incoming calls for medical providers seeking information or assistance.
- Coordinated with internal departments on behalf of providers to ensure timely payment resolution for claims disputes or other financial matters.
- Enhanced customer satisfaction by efficiently resolving provider inquiries and concerns.
- Educated providers on billing procedures, coding guidelines, and reimbursement policies for optimal claim submissions.
- Facilitated smoother claims processing by rigorously verifying provider information.
- Improved provider satisfaction by promptly addressing and resolving service issues.
Member Service Representative
Anthem Inc.
07.2010 - 01.2011
- Helped large volume of customers every day with positive attitude and focus on customer satisfaction.
- Provided exceptional service through active listening, understanding member needs, and offering appropriate solutions.
- Enhanced customer satisfaction by efficiently addressing and resolving inquiries and concerns.
- Maintained high-quality service by adhering to company policies and standards in all member interactions.
- Verified customer identification and documentation for compliant transactions.
- Handled complaints with prompt, courteous service to uphold professional reputation.
Education
BBA - Business Analytics
Old Dominion University
Norfolk, VA05-2028
Skills
- Microsoft SQL
- SQL Developer
- Microsoft 365
- Facets
- Macess Document Management
- NexGen Appeals
- PDASQ Escalations
- Spreadsheet management
- Analytical skills
- Solutions Based Problem Solving
- Teamwork and collaboration
- Scorecard Management
Awards Recognition
Impact Award, 2011 - 2023, Received 18 times for the impacts made across the organization.
Timeline
Network Data Specialist Lead
Anthem Inc.
01.2021 - Current
Network Data Specialist Sr.
Anthem Inc.
01.2018 - 01.2021
Network Data Specialist II
Anthem Inc.
01.2014 - 01.2018
Provider Service Representative
Anthem Inc.
01.2011 - 01.2014
Member Service Representative
Anthem Inc.
07.2010 - 01.2011
BBA - Business Analytics
Old Dominion University
Similar Profiles
MICHELLE COMBSMICHELLE COMBS
Grievance/Appeals Analyst I at ANTHEM INC.Grievance/Appeals Analyst I at ANTHEM INC.
Kaisha RaoKaisha Rao
Outreach Care Specialist II at Anthem Inc.Outreach Care Specialist II at Anthem Inc.
Lisa HoganLisa Hogan
Family Advocate at Anthem Inc.Family Advocate at Anthem Inc.