Summary
Overview
Work History
Education
Skills
Timeline
Generic

Shanesha Mitchell

Midland,GA

Summary

Experienced professional with a strong background in customer service, health insurance eligibility, claims, and appeals. Also experienced in health care client account service and maintenance. Proven ability to drive results through analytical thinking, strategic planning, and organizational skills. Recognized for resolving problems in a timely and effective manner.

Overview

25
25
years of professional experience

Work History

Business Analyst II

Anthem, Inc./Elevance Health
07.2018 - 02.2024
  • Researched, analyzed, and documented business issues
  • Participated in developing and/or modifying business requirements, business design specifications, user training and documentation
  • Translated business requirements to programming staff to ensure requirements were incorporated into system design and testing
  • Managed a book of business and served as main point of contact for eligibility file questions and/or issues
  • Researched and resolved eligibility file discrepancies which included manipulating large amounts of data in Excel
  • Participated in the set-up and any modifications of eligibility file feeds for new and existing clients
  • Managed and ensured weekly enrollment files and annual open enrollment files were received and processed
  • Served as a liaison between users of the software and technical staff
  • Tested and documented solutions.

Grievance & Appeals Analyst Sr.

Anthem, Inc.
10.2003 - 07.2018
  • Summarized and presented essential member/provider appeal case information to the clinical specialists, medical directors, legal counsel and executives, and external reviewers
  • Investigated, summarized, and made recommendations for non-clinical cases
  • Triaged and investigated customer grievances and appeals regarding provision of service and benefit coverage issues
  • Served as the primary point of contact for coordinating and collaborating with delegated entities to ensure compliance with regulatory, accrediting and Health Plan quality of care and service requirements
  • Worked independently to resolve inquiries, grievances, and appeals requests from all customer and product types, related to non-clinical services, quality of care and quality of service issues, and pharmacy issues
  • Handled more complex customer issues requiring adaptation of responses or extensive research
  • Analyzed training programs and workflows to address operational challenges, enhance departmental metrics, increase workplace performance and professional development
  • Researched and analyzed customer feedback data to address operational challenges and customer service obstacles
  • Ensured appropriate resolution to inquiries, grievances and appeals within specified timeframes established by either regulatory and accreditation agencies or customer needs
  • Generated written correspondence presenting the health plan’s position to customers such as members, providers, and regulatory agencies
  • Monitored enterprise tracking system to ensure organization and maintenance of essential files
  • Provided training and support to newer G & A associates.

Customer Care Associate Sr./Market Support Rep Sr.

Blue Cross Blue Shield of Georgia
03.1999 - 10.2003
  • Responded to customer questions via telephone and written correspondence regarding insurance benefits, provider contracts, eligibility, and claims
  • Developed and maintained positive customer relations and coordinated with various functions within the company to ensure customer requests and questions are handled appropriately and in a timely manner
  • Documented inquiry outcomes for accurate tracking and analysis
  • Partnered with Account Managers and Executives to resolve claims, eligibility, benefit and customer service issues
  • Triaged, investigated, and responded to verbal and written correspondence from group administrators and local HR representatives with various issues: benefits, eligibility, claims, etc
  • Served as contact to triage and investigate audit reports and special projects for employer groups
  • Served as health plan representative for offsite meetings with employer groups to discuss claims, customer service and benefit related issues
  • Managed external client facing relationships and partners with corporate and regional business areas
  • Researched and analyzed customer feedback data to address operational challenges and customer service obstacles.

Education

Bachelor of Science/Psychology -

Alabama State University

Master’s level courses in Human Resources Management & Clinical Mental Health -

Troy State University

Skills

  • Solid understanding of health insurance, benefits, claims industry
  • Healthcare business analysis experience
  • Strong analytical, organizational, and problem solving skills
  • Exceptional team building skills
  • Excellent oral, written, and interpersonal communication skills
  • Case management experience
  • Behavioral health experience
  • Data Analysis
  • Requirements Gathering
  • Microsoft Office Suite
  • Project Management

Timeline

Business Analyst II

Anthem, Inc./Elevance Health
07.2018 - 02.2024

Grievance & Appeals Analyst Sr.

Anthem, Inc.
10.2003 - 07.2018

Customer Care Associate Sr./Market Support Rep Sr.

Blue Cross Blue Shield of Georgia
03.1999 - 10.2003

Bachelor of Science/Psychology -

Alabama State University

Master’s level courses in Human Resources Management & Clinical Mental Health -

Troy State University

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Shanesha Mitchell