Shanika Watson
Chicago,IL
Summary
Experienced healthcare professional with a strong record of delivering exemplary service. Skillfully coordinates admission and discharge processes, continuously developing strategies to enhance healthcare management. Highly regarded for problem-solving abilities and effective communication skills. Demonstrates exceptional organizational skills and possesses a comprehensive understanding of data collection and performance metrics.
Overview
10
10
years of professional experience
Work History
Case Management Coordinator
Duly Health and Care
10.2024 - Current
- Maintains all internal data and reporting for Case Management team within the UM Department, including but not limited to:
- Validating monthly member reports to identify potential members for Complex Case Management, Case Management, and Disease Management services.
- Tracking active case management and disease management census on the designated logs.
- Providing assistance with outcomes reporting to quantify the impact of case management services on member population health.
- Logging weekly productivity of Case Management staff by payer and client.
Coordinating other special case management projects and data collection and analysis as needed. - Assists the Nurse Case Managers in: Preparing monthly Clarity and other Case Management reports.
- Compiling discharge lists for post discharge follow up calls.
- Making outreach calls to complete Health Risk Assessment tools and conducts initial interviews to evaluate members' eligibility and needs.
- Referring identified cases to the Nurse Case Manager for follow up.
- Provides member outreach support to CM/DM members by: Overseeing mailings of introductory letters and resources as needed.
- Compiling and updating written and electronic resources.
- Responding to inquiries on the designated case management phone line.
- Serving as point of contact for MXO Tech Case Management and other IPA portals as needed.
- May assist in the processing of ambulatory referrals to meet member needs as directed by Case Management Nurses.
- Provides clerical support to the Case Managers, including faxing, mailing, obtaining medical records from portals, document preparation as needed.
- Scheduling hospital follow up appointments with PCPs and specialists
Compliance Coordinator
SPARC Wellness
12.2019 - 07.2024
- Collect, evaluate, write, and submit data and reports for regulatory bodies.
- Responsible for developing and maintaining tracking and reporting tools to assess Compliance with applicable regulations, and policies and procedures.
- Maintain an up to date knowledge base of industry regulations, including but not limited to, general developments in health law and policies.
- Utilize compliance knowledge and expertise in the development or amendment of required compliance and HIPAA training programs.
- Created reports summarizing findings from internal audits, assessments, and evaluations.
- Maintained records of all compliance activities including investigations, audits, and reviews.
- Identified compliance issues that required follow-up and investigation.
- Prepared reports of activities, evaluations, recommendations, and decisions.
- Verified documentation, implementation and communication of firm and regulatory policies and procedures.
Transition Coordinator
NextLevel Health
04.2018 - 12.2019
- Performed telephonic outreach to waiver program members in accordance with program requirements.
- Supports and oversees the initial and ongoing member transitions in and out of the various Illinois Medicaid programs, the Contractor’s enrollment, and among care settings.
- Facilitate and monitor referrals made to internal Integrated Care Management teams, providers, community-based organizations, and other supportive services.
- Produce and mail routine care management letters and program educational materials to members.
- Serve as an educational resource to members and the provider community
- Provide administrative support to the interdisciplinary team.
- Accurately documented all member interactions and activities within the electronic health record (EHR) in accordance with organizational standards.
- Coordinate, maintain, and monitor data and documentation systems.
- Managed documentation and reporting of preventive health efforts in alignment with organizational goals and compliance standards.
- Maintained oversight of two care coordination mailboxes, facilitating efficient information flow and timely task resolution.
- Facilitate authorization process for Utilization Management.
- Prepared and maintained records and case files detailing clients' personal and eligibility information, services provided and relevant correspondence.
- Mobilized case management system to document service delivery and case progress.
- Ensures the transfer and receipt of all outstanding prior authorization decisions, utilization management data, and clinical information such as prevention and wellness programs(s), care management and complex case management notes.
Program Coordinator I
Centene Corporation – Illinicare Health
05.2017 - 04.2018
- Performed telephonic outreach to members in accordance with program requirements to ensure engagement and continuity of care.
- Verified waiver eligibility through review of DON assessments in IDOA and/or DRS databases.
- Confirmed Medicare and Medicaid eligibility to support accurate care planning and benefit coordination.
- Administered Health Risk Screenings to prioritize members for comprehensive Health Risk Assessments.
- Initiated and submitted authorization requests for home and community-based services, home health, and durable medical equipment (DME) for LTSS and MMP populations.
- Investigated and resolved claims inquiries related to Long-Term Services and Supports (LTSS) and Medicare-Medicaid Plan (MMP) populations.
- Prepared and distributed routine care coordination correspondence and educational materials to members to support informed care decisions.
- Completed and submitted Managed Care Organization (MCO) and ETI forms for members with terminated eligibility.
Customer Service Rep
Centene Corporation – Illinicare Health
06.2016 - 05.2017
- Educated members and/or providers on health plan initiatives
- Trained and assisted providers regarding proper claims billing procedures
- Investigated and resolved complex claims matters in coordination with health plan departments
- Referenced current materials to answer escalated and complex inquiries from members and providers regarding claims, eligibility, covered benefits and authorization status
- Checked procedure codes to confirm allowance amount per Medicaid and Medicare fee schedules
- Discussed submission of the CMS 1500 and UB0400 claim form
Customer Service Rep (Temp for Illinicare)
Alta Staff
08.2015 - 06.2016
- Answered incoming calls
- Reviewed member insurance benefits with the member
- Assisted members with locating a PCP in their community
- Provided current incentive reward balances to members
Education
Some College (No Degree) - Pharmacy
Chicago State University
ChicagoSkills
- Proficiency in a CRM
- Epic
- MEDI
- ECCPIS
- Alert MD
- Charge Capture
- Cisco Jabber
- Webcm
- Virtual Health
- Social Services
- Medicaid/Medicare Waivers
- Case Management
- TruCare
- Meditech
- Microsoft Office
- Microsoft Teams
Timeline
Case Management Coordinator
Duly Health and Care
10.2024 - Current
Compliance Coordinator
SPARC Wellness
12.2019 - 07.2024
Transition Coordinator
NextLevel Health
04.2018 - 12.2019
Program Coordinator I
Centene Corporation – Illinicare Health
05.2017 - 04.2018
Customer Service Rep
Centene Corporation – Illinicare Health
06.2016 - 05.2017
Customer Service Rep (Temp for Illinicare)
Alta Staff
08.2015 - 06.2016
Some College (No Degree) - Pharmacy
Chicago State University
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