Summary
Overview
Work History
Education
Skills
Certification
Timeline
Generic

Shauntalay Randle

Cypress

Summary

Over 19 years of experience as a healthcare professional with 12+ years working with claims and data analysis. Proficient in quality assurance, claims analysis and management principles and practices, medical terminology, ICD-10, CPT Coding, HMO's PPO's, Workers Comp, TRICARE, Medicare and Medicaid, medical records, Risk Adjustment and HEDIS.

Overview

20
20
years of professional experience
1
1
Certification

Work History

Risk Adjustment Program Manger

Apex Systems
06.2023 - Current
  • Utilized electronic medical record systems to store, retrieve and process patient data.
  • Addressed and resolved technical, financial, and operational concerns by working with team members and directors.
  • Met with project stakeholders on regular basis to assess progress and make adjustments.
  • Engaged and worked alongside cross-functional stakeholders to manage strategic initiatives.
  • Integrated decision support, clinical pathways and best practices into health information technology to enhance delivery of care and workflows.
  • Served as liaison between end-users and health IT team.
  • Worked closely with subject matter experts to develop solutions and improvements for clinical systems.
  • Researched and validated clinical data.
  • Applied knowledge, data, information and workflow to develop evidence-based models for health information technology solutions.
  • Led, facilitated and attended focus groups and meetings to strategize workflow issues.
  • Collaborated with stakeholders to drive communication and coordination of health informatics activities and promote accountability.
  • Evaluated and optimized clinical software, applying established and end-user feedback.
  • Employed methods of identifying information, business and technical requirements to meet user complex and unique health information and technology needs.

HEDIS Project Coordinator

Russell Tobin
11.2022 - Current
  • Manages various data organized within Excel spreadsheets
  • Conducts claims research, determining correct service location or verifying member history
  • Performs provider outreach, verifying and confirming provider demographics & medical record requests, both by telephone and in writing
  • Requests medical records and performs follow up of requests within database tools
  • Maintains HIPAA standards and confidentiality of protected health information; reports critical incidents immediately.
  • Demonstrated creativity and resourcefulness through development of innovative solutions.
  • Learned and adapted quickly to new technology and software applications.
  • Identified issues, analyzed information and provided solutions to problems.
  • Completed paperwork, recognizing discrepancies and promptly addressing for resolution.

Medical Record Retrieval Specialist

Altegra Health Solutions
09.2008 - 03.2023
  • Scanned over 300 medical records in day into a secure system to be reviewed by Outcomes medical record coding staff for multiple issues and projects such as HEDIS and Medicare Risk
  • Reviewed over 50 Adjustment Audits daily
  • Retrieved sections of medical records which will be uploaded into a database
  • Identified process improvements in the day-to-day functioning of the department
  • Proved successful working within tight deadlines and a fast-paced environment.
  • Gained strong leadership skills by managing projects from start to finish.

Patient Accounts/Provider Liaison/Claims Processor

OfficeTeam
01.2004 - 01.2015
  • Assisted with reviewing, researching, investigating, negotiating, and resolving all types ofcomplaints/grievances by members, providers and facilities
  • Requested and reviewed of medical records
  • Collected with managed care plans on claims that have not been paid or were not paidcorrectly
  • Responsible for accurate and timely billing of all claims for Medicare, Medicaid, Manage
  • Care, and commercial claims
  • Performed data entry of all physicians and claims at a rate of 30-60 per hour
  • Participated in adjudication of physician claims
  • Performed data entry of all hospital claims data at a rate of 20-40 per hour
  • Prepared and sent correspondence to claimant/provider to resolve claims processingproblems
  • Obtained missing information from physicians, hospitals, and employers by telephone ormail

Gap
09.2013 - Current
  • Worked own Real Estate business

Education

Master of Science - Public Administration

Texas Southern University
Houston, TX
05.2019

Bachelor of Science - Criminal Justice

Columbia College
Columbia, MO
05.2014

Skills

  • Data Communications/Data Collection
  • Medical Records and Documentation
  • Assignment and Project Coordination
  • Risk Management/EPIC EMR
  • Medical Release of Information ROI
  • Patient Health Information Access
  • Skilled in speaking in front of groups
  • Charting and Clinical Documentation
  • Ability and willingness to think outside the box and bring together interdisciplinary teams
  • Effective conflict resolution skills
  • Ability to work with children and families to deliver skills through approved curriculum

Certification

  • Workfront Training -2022
  • Epic 100/130 Training-2022
  • Aethia/Eclinincal/Cerner Training-2015


Timeline

Risk Adjustment Program Manger

Apex Systems
06.2023 - Current

HEDIS Project Coordinator

Russell Tobin
11.2022 - Current

Gap
09.2013 - Current

Medical Record Retrieval Specialist

Altegra Health Solutions
09.2008 - 03.2023

Patient Accounts/Provider Liaison/Claims Processor

OfficeTeam
01.2004 - 01.2015

Master of Science - Public Administration

Texas Southern University

Bachelor of Science - Criminal Justice

Columbia College

Similar Profiles

CREATE PROFILE
Shauntalay Randle