SHANNON LAWS
Baltimore,MD
Summary
Experienced Health Insurance Specialist successful at managing high caseloads in fast-paced environments. Organized, driven and adaptable with excellent planning and problem-solving abilities. Offering over 20 years of experience in health care, appeals, fraud and abuse, claims processing, project management and willingness to take on any challenge.
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Overview
23
23
years of professional experience
Work History
Claims Processor II
CAREFIRST BC/BS
01.2013 - Current
- Accountable for researching, processing, and analyzing commercial, affordable care act (aca) and specialty claims
- Assists management with completion of special projects to reduce case inventory and escalated provider requests
- Resolving claims issues that have been rejected or that may need adjustments
- Software testing for claims
- Responded to customer inquiries, providing detailed explanations of insurance policies and claims processes.
- Collaborated with cross-functional teams to resolve complex claims issues efficiently and effectively.
Customer Service Representative II
CAREFIRST BC/BS
05.2007 - 12.2012
- Explain benefits and plan specific policies and procedures to ensure that provider and members are appropriately utilizing covered services
- Assists management with completion of special projects to reduce case inventory and escalated provider requests
- Resolving claims issues that have been rejected or that may need adjustments
- Successfully completes appropriate documentation in accordance with FEP regulations and guidelines
- Clarified customer issues and determined root cause of problems to resolve product or service complaints.
- Conducted regular quality assurance checks on interactions with customers to ensure agents were meeting established guidelines and standards for service excellence.
Credentialing Specialist
Adecco
07.2006 - 05.2007
- Conducted primary source verifications such as background checks and board certifications
- Conducted audits of provider files, ensuring all necessary documents were up-to-date and compliant with regulatory requirements.
- Safeguarded confidential provider information by adhering to strict data privacy regulations and company policies.
Assistant General Manager
DavCo Restaurants
01.2005 - 06.2006
- Motivated, trained, and disciplined employees to maximize performance
- Tracked employee attendance and punctuality, addressing repeat problems quickly to prevent long-term habits.
- Oversaw inventory management processes to maintain proper stock levels and minimize spoilage or waste.
- Monitored daily cash discrepancies, inventory shrinkage, drive-off and prepared deposits.
- Managed team schedule with eye for coverage needs and individual strengths.
- Assisted in recruiting, hiring and training of team members.
Sr. Appeals Analyst, Medical Review
CAREFIRST BC/BS
01.2004 - 10.2005
- Coordinated and forecasted all appeals activities for mandates in the Medicare Part A program
- Analyzed appeal trends and developments for provider education, program safeguard activities and managed special projects as required
- Communicated with the provider community via telephone and through written correspondence to ensure resolution of complex appeals and claim issues
- Instructed providers, persons with Medicare, Beneficiary Representatives and internal associates on appeal procedure and regulations and benefit coverage
- Met with the Medical Review Team to formulate Corrective Action Plans for Providers and assists with the development of Appeals SOPs as required
- Submitted reports to the Center for Medicare and Medicaid Services
- Met with corporate auditors and representatives of the CMS
- Coordinated and update the Business Continuity Plan for the department
- Recorded and track possible Fraud and Abuse issues.
Administrative Assistant, Medical Review
CAREFIRST BC/BS
01.2001 - 01.2003
- Provided administrative and clerical support for the Medical Review Staff and Division
- Submitted reports to the Supervisor and the Center for Medicare and Medicaid Services
- Recorded and track possible Fraud and Abuse issues
- Participated in monthly Program Safeguard meetings
- Managed special projects
- Restocked supplies and placed purchase orders to maintain adequate stock levels.
Education
Ph.D. - Pastoral Counseling
Family Bible Seminary
Baltimore, MDMaster of Arts - Divinity
Family Bible Seminary
Baltimore, MDNo Degree - Business Administration
Strayer University
Washington, DCSkills
- Documentation processing
- Records Management
- Accuracy and Precision
- Large-Sum Computations
- Insurance Regulations Understanding
- Payment and Investigation Escalations
- Policy Interpretation
- Regulatory Compliance Adherence
- Claims adjustment
- Data Management
- Organization and Time Management
- Analytical and Critical Thinking
Work Phone
443-471-5540
Timeline
Claims Processor II
CAREFIRST BC/BS
01.2013 - Current
Customer Service Representative II
CAREFIRST BC/BS
05.2007 - 12.2012
Credentialing Specialist
Adecco
07.2006 - 05.2007
Assistant General Manager
DavCo Restaurants
01.2005 - 06.2006
Sr. Appeals Analyst, Medical Review
CAREFIRST BC/BS
01.2004 - 10.2005
Administrative Assistant, Medical Review
CAREFIRST BC/BS
01.2001 - 01.2003
Ph.D. - Pastoral Counseling
Family Bible Seminary
Master of Arts - Divinity
Family Bible Seminary
No Degree - Business Administration
Strayer University
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