Shanesha Houston
Winston-Salem,NC
Summary
Skillful Medicaid Operations Analyst adeptly supporting system management and problem resolution to improve records management. Over 10 years of experience managing customer activity, addressing technical issues and maintaining system operations. Skillfully assessed operational procedures, providing hands-on experience analyzing records and investigating complex troubleshooting issues. Accomplished expert navigating latest compliance regulations and service-level agreements, maintaining strict compliance with updated standards. Highly experienced in many different lines of business such as commercial (individual and Group), Federal Employment Program, Student Blue accounts, Medicaid, and Medicare.
Overview
11
11
years of professional experience
Work History
Medicaid State Operations Analyst
Elevance Health
10.2022 - Current
- Review and Analyze Top Denials Globally and triage denials on a provider level
- Coordinate training with employees for PCP Data and provider termed notifications
- Provide support for Help Center Tickets ensuring root cause is identified and resolved
- Ensure all provider outreach attempts are conducted, in addition to analyzing claims reports for completion
- Identify trends that may result in pricing/benefit configurations
- Coordinate implementation and monitor post-implementation for pricing/benefit configurations
- Collaborate with business partners to ensure provider data is accurately displaying in Facets systems
- Collaborate with enrollment to process PCP reassignments
- Track and monitor Interest and Penalties to identify any issues
- Provide feedback to employees regarding claims are process concerns.
- Created custom reports and visualizations to support decision-making processes.
- Investigated and resolved alerts, conducted queries and culled records to assist with maintenance and problem resolution.
Network Data Specialist II
Elevance Health
04.2021 - 10.2022
- Validates the data to be housed on provider databases and ensuring adherence to business and system requirements as it pertains to contracting, network management and credentialing
- Research and resolve complex exceptions, error reports, PCP Assignments
- Ensure accurate reimbursement based on provider contract and area fee schedules
- Receiving and responding to state or federal regulatory complaints
- Managing Operations Inquiry Tracker consisting of provider disputes/complaints
- Pull claims impact reports for claims sweeps
- Identify any overpayment/underpayments
- Perform procedure codes audits
- Evaluated efficiency and reliability of internal data management systems to identify and correct deficiencies.
Customer Care Rep I-II
Anthem BCBS
08.2019 - 04.2021
- Help to guide members and providers with their healthcare needs by explaining benefits, solving claim concerns, helping find a doctor via telephone calls, online chats or e-mails
- Complete callbacks and provide detailed feedback and research on Medallia Surveys
- Assist with quality audits
- Conduct member outreach regarding essential health benefits
- Focus on proactively resolving our members and/or providers questions and concerns using computer-based resources to find answers
- Partner internally to create a seamless experience for our customers and resolve potential issues
- Guide members and providers with their healthcare needs by explaining benefits, solving claim concerns, helping find a doctor via telephone calls, online chats or e-mails.
Health Concierge
Aetna
04.2019 - 08.2019
- Educate and advise callers on their benefits, the system, and all related processes
- Process enrollment related transactions and take ownership of issues through resolution
- Research customer requests and follow up with customers as needed
- Assist with company projects and administrative tasks.
- Maintained full and current understanding of available plans, products and services.
- Provided information such as copay and premium details, pre-approval procedures and available products.
Customer Solutions Expert
Blue Cross NC
11.2017 - 07.2018
- Ensures final disposition of each inquiry in a timely manner while systematically documenting detailed customer information relevant to each customer contact
- Assist in handling high volume of incoming calls related to claims, billing, and insurance eligibility
- Update/process Student Blue waivers, applications, and enrollment on production quotas
- Lines of Business: Commercial: Individual and Large Group
- Resolved customer complaints quickly and professionally to restore customer confidence and prevent loss of business.
- Followed up on customer interactions to maintain customer communication and successfully close resolved issues.
Customer Service Specialist
Blue Cross NC
07.2014 - 10.2017
- Recognize patterns of inconsistent and/or inaccurate claims filing practices among customers and providers
- Processed high level refund requests regarding claims and member premiums
- Assist in eligibility/enrollment of member in ACA plans through the Healthcare Exchange
- Provide training for Customer Escalations Analysts handling high level dispute with the DOI
- Complete member cancellation, reinstatement, and retention requests
- Lines of Business Commercial and Federal Employment Program.
- Maintained customer satisfaction with forward-thinking strategies focused on addressing customer needs and resolving concerns.
- Addressed customer complaints and mitigated dissatisfaction by employing timely and on-point solutions.
Customer Service Team Lead
EMS management and consultants
08.2013 - 07.2014
- Conduct Bi-weekly Training for customer service representatives
- Handle escalated issues/calls with Emergency Medical Services for Debt set off and Collections
- Provide coaching and feedback ensuring customer satisfaction and employee compliance
- Coached new team members on service techniques and provided scoring through quality assurance program.
- Promoted to team lead of customer service for displaying outstanding enthusiasm and remaining calm in extremely trying situations.
Customer Service Specialist
EMS management and consultants
08.2012 - 08.2013
- Resolve patients concerns and assist with billing while building relationships
- Identify, understand, and anticipate customers’ unexpressed needs and concerns in a caring manner
- Detect caller patterns and provide appropriate feedback to supervisor to reduce or prevent possible future calls.
- Addressed customer complaints and mitigated dissatisfaction by employing timely and on-point solutions.
- Achieved high satisfaction rating through proactive one-call resolutions of customer issues.
- Complied with company policies and procedures by encouraging positive and effective work environment among employees.
Education
Master of Healthcare/Business Administration -
Pfeiffer University
Misenheimer, NC08.2017
Bachelor of Healthcare Management -
Winston-Salem State University
Winston-salem, NC05.2012
Skills
- Ability to review, identify data, and draw sound conclusions
- Highly organized with sound time management skills
- Ability to clearly and concisely communicate verbally and in written form while dealing with irate customers regarding controversial and confidential matters
- Ability to perform math calculations, use Microsoft Office applications such as Word and Excel
- Microsoft PowerPoint
- Ability to always maintain rational behavior, demonstrate courteous, professional, and efficient
Timeline
Medicaid State Operations Analyst
Elevance Health
10.2022 - Current
Network Data Specialist II
Elevance Health
04.2021 - 10.2022
Customer Care Rep I-II
Anthem BCBS
08.2019 - 04.2021
Health Concierge
Aetna
04.2019 - 08.2019
Customer Solutions Expert
Blue Cross NC
11.2017 - 07.2018
Customer Service Specialist
Blue Cross NC
07.2014 - 10.2017
Customer Service Team Lead
EMS management and consultants
08.2013 - 07.2014
Customer Service Specialist
EMS management and consultants
08.2012 - 08.2013
Master of Healthcare/Business Administration -
Pfeiffer University
Bachelor of Healthcare Management -
Winston-Salem State University
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