Shawnna Allen
Tampa,FL
Summary
About Me Strong expertise in claims, and performance enhancement. Excellent communication skills, attention to detail, and commitment to providing quality care. Experienced Supervisor leading team members on-time job completion. Assign tasks, train employees, provide feedback, mediate interpersonal conflicts and implement company procedures. Excellent communication and listening skills. Provide leadership and vision which drives teams to meet goals. Detail-oriented team player with strong organizational skills. Ability to handle multiple projects simultaneously with a high degree of accuracy.
Overview
16
16
years of professional experience
Work History
Sr. Claims Liaison Supervisor III
WellCare Health Plans/Centene Corporation Remote Home Based
01.2019 - Current
- Project management and new department development
- Developer of processes and procedures for new departments inquired from other outside unties inquired by the corporation
- Train all current and new venders/corporate agents on processes and procedures created for all polite programs and test environments within the sector of Member Services, Providers Services and Provider operations.
- Applied strong leadership talents and problem-solving skills to maintain team efficiency and organize workflows.
- Monitored workflow to improve employee time management and increase productivity.
- Evaluated employee performance and coached and trained to improve weak areas.
- Enforced rules and regulations outlined in company manual to set forth expectations comprehensibly and consistently.
- Boosted team performance by developing customer service training materials and conducting service training.
- Developed and implemented customer service policies to enhance satisfaction.
- Solicited customer feedback to identify and improve on areas of weakness.
- Evaluated staff performance and provided coaching to address inefficiencies.
- Achieved results by working with staff to meet established targets.
Sr. Resolutions Representative
WellCare Health Plans
01.2018 - 01.2019
- Handle escalated inbound and outbound calls, emails, and tickets from AHCA, CMS, CTM, CEO company complaints for both members who are enrolled with company
- Oversee and assist participating, and non-participating providers with all WellCare members claims inquires, issues, and or concerns with billing processing, and configuration, is now
- Used customized ticketing system and kept detailed notes and documentation on incidents.
- Collaborated with various groups to troubleshoot and resolve build and deployment issues.
- Responded to customer inquiries and provided detailed account information.
- Entered client details and notes into system for interdepartmental access and review.
Sr. Resolution Specialist
WellCare Health Plans
01.2015 - 01.2018
- I assist providers with claims issues that are escalated over due to high priority levels
- I adjust claims that are High Dollars, underpaid, paid in error and or encountered a system issue to where claim where never processed and or paid due to provider billing error
- Process all Medicare and Medicaid claims submitted from participating, non-participating providers all facilities stand alone and labs, with escalated issues, denials, and pricing issues
- Assist provider pick issues via Field Magic Ticket, Re-run, EDI, Configurations, etc
- For claims adjustments if needed, assist with provider contact to (PR) provider Reps for contracts, configurations, demographics, payment integrity, EOB/EOP contact, F status, contact, updated for claims payments, and all other provider/ hospital, labs specialty, etc
- Facilities inquire’ s escalated issues
- Assist with all claim denials, payment inquiries, rejected claims, encounter claims, DME claims
- Part B claims, wrap claims, Balance billing inquires, pricing issues, contracting issues, all participation and non-participating providers/ hospitals, labs specialties, etc
- Facilities inquire’ s by educating providers and all facilities, adjusting claims when claim had claim error due to
- WellCare system issues, pricing claim when claim aren’t pricing in system per providers contracts, and provider correspondence for providers services, and provider operation services.
- Leveraged consistent, successful strategies to meet and exceed performance goals.
Sr. Pharmacy Representative
WellCare Health Plans Pharmacy Help Desk
01.2014 - 01.2015
- Assist providers, pharmacy, hospitals, and members with prescriptions refills for specialist compound, injectable, brands and generic medications, vacation overrides, early and or emergency fills, controlled substances fill, diabatic insulin fills, ESRD injectable, an all-other specialty injectable and medications
- Submit and process oral and or written faxed prior authorizations for both members and providers for medications requiring an authorization for all medical necessity, step therapy and controlled substance medications
- Submit and process oral and or written faxed prior authorizations, appeals authorization or not covered by member's plan, and place oral appeals for denied authorizations, and any other pharmacy related issues for both Medicare, and Medicaid part D and part B
- Research issues for resolution within an expedited turnaround time frame and while providing quality standards when assisting with special projects, and train new hires assigned or directed.
- Entered and processed patients' prescriptions into internal system.
- Performed various pharmacy operational activities with strong commitment to accuracy, efficiency, and service quality.
- Assisted pharmacist by filling prescriptions for customers and responding to patient questions regarding prescription and medication-specific issues.
- Collected co-payments or full payments from customers.
- Communicated with patients to collect information about prescriptions and medical conditions or arrange consultations with pharmacists.
- Resolved third-party billing, computer system and customer service issues.
- Set up and modified patient profiles to include current medications and insurance details.
- Prepared packaging and labels for prescriptions, verifying accuracy of dosage, side effects, interactions, and refill instructions.
- Coordinated verification and filling of more than 100 daily prescriptions in high-volume over 100,000 Mail Order/Specialty prescription pharmacy environment.
Pharmacy Representative
WellCare Specialty Pharmacy/Exactus Specialty Pharmacy
01.2011 - 01.2014
- Project management and new department development
- Trained CSR on and off site with other departments within WellCare on pharmacy systems, pharmacy processes and procedures, pharmacy protocols and step action tools for navigation
- Caremark and all other hospital, facilities, and all other stand a long pharmacy orders, payments, and escalated calls to prevent supervisor escalations
- Trained agents on how to process mail order fills with outside venders Express Scripts, CVS
- Caremark and all other outside venders who called for fills, refills, denials, authorization, and appeals concerns
- Answered escalated Inbound/outbound calls from level 2 customer service with member complaints transferers concerning all pharmacy related issues.
- Entered and processed patients' prescriptions into internal system.
- Performed various pharmacy operational activities with strong commitment to accuracy, efficiency, and service quality.
- Consulted with insurance company representatives to complete claims processing, resolve concerns, and reconcile payments.
- Collected co-payments or full payments from customers.
- Communicated with patients to collect information about prescriptions and medical conditions or arrange consultations with pharmacists.
Sr. Customer Service Representative
United Health Care Group
01.2008 - 01.2010
- Took inbound calls for Medicare and Medicaid members
- Provided claims status, benefit coverages, and eligibility statues for member patients, to
- Participating and Non-Participating providers, and unities
- Assist members, providers, and venders such as Durable Medical Equipment (DME), LTC, Skilled
- Nursing Facilities, Hospitals, Specialists, Ancillary, Transportation, Dental, Vision, Prescription benefits to both members/providers and Hospice's, coverages/eligibility
- Assists and provided claims /benefits/enrollment information and details for all members enrolled in United Health Care Group under plans such as: Evercare, Tricare, and Secure
- Horizons Medicare and Medicaid Replacement programs.
- Responded to customer calls and emails to answer questions about products and services.
- Stepped up to assist customer service manager with complaints and issues during times of department short staffing.
Education
Medical Insurance Coding & Medical Billing Certification -
College Concord Career Institute Vocational Medical School
11.2008
High School Diploma -
Harvest Time Christian Academy
05.1999
Skills
- Communication
- Problem-solving
- Project Management
- Collaborate Effectively
- Project Department Developer
- Technical Proficiency
- Policy Enforcement
- Shift Coverage
- Supervising Employees
- Agent Assistance
- Leadership
- Business Analysis
- Productivity Performance
- Performance Motivation
- Continuous Improvement Projects
- Business Administration
- Employee Coaching and Mentoring
- Processes and Procedures
- Training and Development
- Motivating Performers
- Complex Problem-Solving
Work Availability
monday
tuesday
wednesday
thursday
friday
saturday
sunday
morning
afternoon
evening
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Timeline
Sr. Claims Liaison Supervisor III
WellCare Health Plans/Centene Corporation Remote Home Based
01.2019 - Current
Sr. Resolutions Representative
WellCare Health Plans
01.2018 - 01.2019
Sr. Resolution Specialist
WellCare Health Plans
01.2015 - 01.2018
Sr. Pharmacy Representative
WellCare Health Plans Pharmacy Help Desk
01.2014 - 01.2015
Pharmacy Representative
WellCare Specialty Pharmacy/Exactus Specialty Pharmacy
01.2011 - 01.2014
Sr. Customer Service Representative
United Health Care Group
01.2008 - 01.2010
Medical Insurance Coding & Medical Billing Certification -
College Concord Career Institute Vocational Medical School
High School Diploma -
Harvest Time Christian Academy
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