Sheila Heyward
Summerville,SC
Summary
Experienced denial management specialist with strong track record in healthcare claims processing and resolution. Skilled in processing claims, insurance verification, addressing claim denials and authorization management. Effective at ensuring compliance with industry regulations and optimizing reimbursement processes. Known for effective team collaboration, adaptability to changing needs, and results-driven approach. Proficient in utilizing streamline processes, insurance protocols, and at improving workflow efficiency.
Overview
14
14
years of professional experience
Work History
Claim Benefit Specialist
CVS Aetna Medicaid
01.2022 - 07.2024
- Assist with special projects, data entry and call tracking to support company and team goals
- Audit claims processing by streamlining PCQ (pre-check query) reports to ensure accuracy prior to claims going out incorrectly
- Resolve and make necessary adjustments on claims received directly from patient health plans
- Processed over 100 medical/hospital claims with an accuracy exceeding 99%, contributing to team efficiency
- Acted as subject matter expert by providing training, conducting team meetings, or responding to management regarding various complex issues.
- Manually processed high dollar inpatient Medicaid claims using DRG calculators
- Maintain an in-depth understanding of UB-04 and CMS-1500 claim forms, ensuring all required fields are completed accurately for processing
Referral Specialist
PHC (Pharmaceutical Health Care) Home Health
01.2019 - 01.2022
- Verified insurance coverage via phone or portals and audit documentation from referral sources while leading to reduced errors
- Maintained effective communication with physicians, medical office staff, and payers to resolve authorization discrepancies
- Initiated and secured essential referrals, pre-certifications, and authorizations to ensure eligibility and compliance for services
- Submit prior authorizations to insurances through payer-specific portals and adhering to deadlines
Authorization Verification Specialist
VieMed Health Care
01.2017 - 01.2019
- Conducted comprehensive reviews of progress notes and insurance verification to ensure compliance with authorization requests and payer guidelines
- Managed submission and follow-up of authorizations and appeals via phone, fax, and online platforms
- Assisted with Out-of-Network authorization project with results of 2.5% revenue increase within the first six months of the project
Referral Intake Coordinator
Sea Island Comprehensive Healthcare
01.2016 - 01.2017
- Obtain patient referral information from referral sources via phone or website
- Maintained current knowledge of Medicare, Medicaid, Commercial and other payer source requirements for reimbursement services of home health services
- Obtain complete information like H&P, F2F, valid orders medical records, and insurance information of the patient
BCBS Billing and Claim Specialist
Tri-Med Healthcare
01.2015 - 01.2016
- Review BCBS claims to process claim reconsideration for denied claims for DME max, purchase price, not medically necessary, no authorization, investigational and no out- of- network benefits
- Updated medical policy and guidelines on the company's intranet to maintain accurate and current information for internal use
- Verified benefits and conducted follow-up calls with providers, while managing and prioritizing daily tasks related to appeals and denied claims
Billing Specialist
Hill-Rom Company
01.2011 - 01.2014
- Facilitated timely billing processes while ensuring adherence to government regulations
- Reviewed and corrected claim codes, leading to successful resubmission of accurate invoices
- Collaborated with billing department and sales representatives to meet and exceed billing objectives
- Managed customer accounts with confidentiality and kept records of customer interactions, transactions, inquiries, comments and complaints
Education
Bachelor of Arts - Business Administration/Management
Francis Marion University
Florence, SCSkills
- Claims Adjudication & Processing
- Insurance Verification & Authorizations
- Compliance (OSHA, HIPAA)
- Problem-solving
- JD Edwards, Axxess Networks, and QNXT Systems
- Data Entry & Documentation Follow-Up
- Professional Communication & Team Collaboration
Quickbase Systems
Timeline
Claim Benefit Specialist
CVS Aetna Medicaid
01.2022 - 07.2024
Referral Specialist
PHC (Pharmaceutical Health Care) Home Health
01.2019 - 01.2022
Authorization Verification Specialist
VieMed Health Care
01.2017 - 01.2019
Referral Intake Coordinator
Sea Island Comprehensive Healthcare
01.2016 - 01.2017
BCBS Billing and Claim Specialist
Tri-Med Healthcare
01.2015 - 01.2016
Billing Specialist
Hill-Rom Company
01.2011 - 01.2014
Bachelor of Arts - Business Administration/Management
Francis Marion University
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