Shawn Favors
Managed Care Professional
Lithia Springs,GA
Summary
Experienced leader with strong background in guiding teams, managing complex projects, and achieving strategic objectives. Excels in developing efficient processes, ensuring high standards, and aligning efforts with organizational goals. Known for collaborative approach and commitment to excellence.
Overview
26
26
years of professional experience
Work History
Utilization Management Manager
Mosaic Health
Rochester
04.2022 - Current
- Led a team of 21 non-clinical UM professionals overseeing prior authorization requests.
- Negotiated Single Case Agreements to secure timely, cost-effective out-of-network care.
- Analyzed daily operational reports to monitor turnaround times and denial trends.
- Developed strategic partnerships with internal departments and external vendors for care coordination.
- Ensured compliance with CMS, NCQA, and URAC standards; implemented process improvements for efficiency.
- Collaborated with medical directors to align clinical decisions with utilization goals.
Claims Manager
Amerigroup
Tampa
03.2021 - 04.2022
- Led 31 staff across Claims, Cash Receipts, Adjustments, and Payment Integrity teams, ensuring high performance and accountability
- Implemented KPIs to improve processing speed, accuracy, and customer satisfaction
- Cultivated strategic partnerships with internal stakeholders to streamline workflows and expedite issue resolution
- Delivered executive reports and dashboards to support leadership decisions
- Led quality reviews and risk mitigation efforts for high-cost claims
Medicaid State Operations Analyst
Amerigroup
Virginia Beach
10.2018 - 03.2021
- Managed Medicaid operations to ensure compliance with state regulations, contractual obligations, and audit requirements
- Led claim escalation reviews, pricing and agreement ID updates, and resolution of Medicaid state complaints
- Directed global, proactive, and validation projects; developed statements of work (SOWs) and managed timelines, resources, and deliverables
- Conducted root cause analyses to resolve systemic issues in claims, eligibility, and provider data
- Supported market-specific initiatives and collaborated with cross-functional teams to execute state-driven tasks
- Delivered insights through executive reporting and performance reviews to inform leadership decisions and policy alignment
Recovery Audit Analyst
Amerigroup
Virginia Beach
04.2014 - 10.2018
- Conducted comprehensive audits to identify and recover overpayments in medical and pharmacy claims, driving measurable cost savings for the health plan
- Performed root cause analysis to uncover systemic billing and payment errors; collaborated with claims, finance, and compliance teams to implement corrective actions
- Managed the full recovery lifecycle including provider engagement, appeals handling, and claim adjustments to ensure timely and accurate recoupments
- Designed and maintained detailed reports and dashboards to monitor recovery performance, identify trends, and support strategic decision-making by leadership
- Ensured all audit and recovery activities complied with CMS, Medicaid, and commercial payer regulations and internal policies
- Provided actionable insights through data analysis that informed enterprise-wide cost containment initiatives and process improvements
Utilization Management Representative II
WellPoint, Anthem Blue Cross
Indianapolis
01.2013 - 04.2014
- Performed medical necessity reviews to ensure compliance with clinical guidelines and payer policies
- Collaborated with physicians and case managers to support timely, appropriate care coordination
- Made utilization decisions balancing quality care and cost-efficiency
- Communicated clinical determinations clearly to providers, members, and stakeholders
- Analyzed utilization trends to drive process improvements and better member outcomes
- Maintained compliance with regulatory standards through accurate documentation and audit support
Claims Representative III
Blue Cross Blue Shield of GA
atlanta
01.2000 - 01.2013
- Managed complex claims adjudication, applying expert knowledge of policies, contracts, and regulatory guidelines to ensure accurate and timely payments
- Exercised sound judgment in resolving escalated claims issues, reducing denials and minimizing financial risk
- Collaborated with cross-functional teams including providers, legal, contracting, membership and finance to address claims disputes and streamline workflows
- Analyzed claims data to identify trends, inform process improvements, and support efficiency
- Mentored junior claims staff, promoting best practices and continuous learning
Education
High School Diploma -
Glen Oaks High School
Baton Rouge, LA05-1992
Skills
- Utilization managStrategic Planning & Operational Efficiency
- Cross-Functional Team Leadership & Development
- Regulatory Compliance & Risk Mitigation
- Payment Integrity & Overpayment Recovery
- Vendor Management & Strategic Partnerships
- Cost Containment & Root Cause Analysis
- Claims Operations & Project Management
- Coaching, Mentoring & Performance Management
- Employee Relations & Change Management
References
References available upon request.
Work Type
Full TimeContract WorkWork Location
RemoteImportant To Me
Career advancementWork-life balancePersonal development programsHealthcare benefitsWork from home optionPaid time offFlexible work hoursCompany CultureTimeline
Utilization Management Manager
Mosaic Health
04.2022 - Current
Claims Manager
Amerigroup
03.2021 - 04.2022
Medicaid State Operations Analyst
Amerigroup
10.2018 - 03.2021
Recovery Audit Analyst
Amerigroup
04.2014 - 10.2018
Utilization Management Representative II
WellPoint, Anthem Blue Cross
01.2013 - 04.2014
Claims Representative III
Blue Cross Blue Shield of GA
01.2000 - 01.2013
High School Diploma -
Glen Oaks High School
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