Shaniqua McClain
Jacksonville,FL
Summary
Healthcare Operations and Utilization Management professional with experience supporting patient care, prior authorizations, insurance verification, claims resolution, appeals, member services, and healthcare administration. Proven ability to improve operational efficiency, resolve complex member and provider issues, and ensure compliance with health plan requirements. Experienced in managing high-volume workloads while delivering exceptional customer service and maintaining accuracy in regulated healthcare environments.
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Overview
17
17
years of professional experience
Work History
Clinical Support Specialist
Florida Blue
Jacksonville, FL
09.2017 - 04.2026
- Process and submit prior authorization requests for inpatient admissions, outpatient procedures, diagnostic testing, and specialty services while ensuring compliance with health plan guidelines and regulatory requirements.
- Manage high-volume authorization and referral requests, supporting timely care coordination for members and providers.
- Resolve complex benefits, claims, enrollment, and coverage inquiries while maintaining high customer satisfaction and service quality standards.
Receptionist
ERC
Jacksonville, FL
11.2013 - 07.2017
- Handled multi-line phone system, directing calls to appropriate departments with professionalism.
- Greet all clients/agents/ upon arrival sign in all visitors and verifying ID.
- Responsible for all supplies and inventory coming in and out.
- Supported office efficiency by performing clerical tasks such as data entry, photocopying, scanning, and faxing documents.
Front Desk Medical Receptionist
Summit Women's Health Care
Albany, GA
01.2009 - 08.2013
- Greet patients warmly and manage multi-line phone systems with professionalism and courtesy, ensuring excellent customer service at all times.
- Schedule appointments accurately using EMR (Electronic Medical Records) systems, while coordinating care plans and follow-up visits.
- Verify insurance coverage and benefits, ensuring proper documentation review for billing accuracy. Submit prior authorization.
- Handle medical billing and collections efficiently by processing payments, submitting claims, and following up on unpaid accounts in compliance with HIPAA regulations.
- Maintain organized medical records by filing documents correctly, managing electronic files in systems, and ensuring the confidentiality of health information.
- Assist with intake procedures, including collecting patient information, updating records, and explaining clinic policies clearly.
Education
High School Diploma -
Albany High School
Albany, GA05.2005
Bachelor of Science - Health Administration
University of Phoenix
Tempe, AZ03-2027
Skills
- Claims
- Availity
- HIPAA compliance
- Insurance verification
- Prior authorizations
- Co-pay collection
- Multi-line phone systems
- Patient check-in/out
- ICD-10 basics
- Benefits Verification
- Referral Management
- Patient care
Timeline
Clinical Support Specialist
Florida Blue
09.2017 - 04.2026
Receptionist
ERC
11.2013 - 07.2017
Front Desk Medical Receptionist
Summit Women's Health Care
01.2009 - 08.2013
High School Diploma -
Albany High School
Bachelor of Science - Health Administration
University of Phoenix