Sheila Heyward
Summary
Detail-oriented healthcare administration professional with expertise in claims adjudication, insurance verification, authorization, and overpayment recovery. Seeking a challenging position where I can utilize my skills in claims processing, compliance, and team collaboration to contribute to efficient and accurate overpayment recovery and claims management.
Overview
14
14
years of professional experience
Work History
Claim Benefit Specialist
CVS Aetna Medicaid
Virginia
01.2021 - Current
- Acquired comprehensive knowledge of client’s claims adjudication systems, member and provider contracts, and claim payment policies.
- Performed claims rework calculations ensuring compliance with client requirements and validated claims to confirm algorithm accuracy and prevent duplicate refunds.
- Assisted in identifying, validating, and recovering claim overpayments, collaborating with clients to ensure resolution.
- Reviewed and resolved disputed overpayments from both clients and providers, ensuring accurate documentation and communication.
- Participated in knowledge sharing sessions to brainstorm and resolve claim issues and seek clarifications, contributing to team success.
- Audited COB claims to determine correct resolution pathways and assisted with special projects, data entry, and call tracking to support company goals.
- Communicate with other departments, team members, and management regarding various issues
- Adhere to all company and departmental policies and procedures to maintain compliance and contribute to a positive work culture.
Referral Specialist
PHC (Pharmaceutical Health Care) Home Health
James Island, SC
01.2019 - 01.2021
- Gathered information from insurance carriers and other staff to ensure patient's financial obligations were met
- Provided administrative support to clinical staff for referral services
- Entered referrals and documented communications in the information system
- Verified insurance coverage and obtained authorizations if necessary
- Acted as a liaison between hospitals, physicians, health plans, and patients
- Ensured patients were cleared for specialty service office visits
- Document activities accurately in process notes to maintain clear records
- Submit prior authorizations to insurances through payer-specific portals and vendors, adhering to deadlines.
Authorization Verification Specialist
VieMed
Lafayette, LA
01.2017 - 01.2019
- Reviewed progress notes and insurance verifications for authorization requests
- Researched payer insurance guidelines to ensure compliance
- Sent notifications to relevant departments regarding turnaround times
- Submitted authorizations via phone, fax, and online platforms
- Made outbound calls to follow up on authorizations and appeals.
Referral Intake Coordinator
Sea Island Comprehensive Healthcare
Johns Island, SC
01.2016 - 01.2017
- Obtained patient referral information and verified eligibility
- Liaised with referral sources and obtained necessary documentation
- Maintained knowledge of state and federal guidelines applicable to home care
- Performed data entry for patient information and authorization of service.
BCBS Billing and Claim Specialist
Tri-Med Service
Mt. Pleasant, SC
01.2015 - 01.2016
- Reviewed BCBS claims and processed claim reconsiderations
- Updated medical policy and guidelines on the company's intranet
- Verified benefits and made follow-up calls with providers
- Managed and prioritized daily tasks for appeals and denied claims.
Billing Specialist
Hill-Rom Company
Charleston, SC
01.2011 - 01.2014
- Ensured timely billing and compliance with government regulations
- Reviewed claims for correct coding and resubmitted corrected bills
- Communicated with billing department and sales representatives to achieve billing goals.
Education
Skills
- Claims Adjudication & Processing
- Overpayment Identification & Recovery
- Insurance Verification & Authorizations
- Compliance (OSHA, HIPAA)
- Data Entry & Documentation
- Billing Discrepancy Resolution
- Trend Identification & Root Cause Analysis
- JD Edwards, Axxess Networks, QNXT Systems
- Microsoft Office Suite
- Professional Communication & Team Collaboration
References
Available upon request
Timeline
Claim Benefit Specialist
CVS Aetna Medicaid
01.2021 - Current
Referral Specialist
PHC (Pharmaceutical Health Care) Home Health
01.2019 - 01.2021
Authorization Verification Specialist
VieMed
01.2017 - 01.2019
Referral Intake Coordinator
Sea Island Comprehensive Healthcare
01.2016 - 01.2017
BCBS Billing and Claim Specialist
Tri-Med Service
01.2015 - 01.2016
Billing Specialist
Hill-Rom Company
01.2011 - 01.2014
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