RN
Sheila Wilson-Doby
CareFirst
College Park,MD
1
Certification
29
years of professional experience
Highly organized and hardworking with excellent planning and program management skills. Licensed in DC. To seek and maintain part-time position that offers professional challenges utilizing interpersonal skills, excellent time management and problem-solving skills.
Work History
Manager -Clinical Medical Review
9 Years 9 Months- Evaluated medical guidelines and benefit coverage to determine appropriateness of services.
- Facilitated workgroup meetings with medical personnel to find effective solutions to issues.
- Served as subject matter resource, providing information related to medical claims review situations.
- Cultivated positive rapport with fellow employees to boost company morale and promote employee retention.
- Managed daily medical claims reviews, operational and administrative actives.
- Maintained consistent medical review process which addressed adverse decisions and contractual issue based on State and Federal regulatory requirements.
- Cross-trained existing employees to maximize team agility and performance
- Accomplished multiple tasks within established timeframes
- Managed over 25 professional and non-professional personnel.
- Directed staff performance, coaching, and scheduling to maintain consistent service delivery and workflow coverage.
- Implemented procedure updates to strengthen compliance, accuracy, and consistency across daily operations.
- Partnered with internal stakeholders to resolve escalated issues and support timely member and provider responses.
- Established performance goals for employees and provided feedback on methods for reaching those milestones.
Clinical Review Supervisor
11 Years 4 Months- Managed 15+ professional and non-professional staff.
- Helped create new policies
- Maximized performance by monitoring daily activities and mentoring team members.
- Reviewed performance data to monitor and measure productivity, goal progress and activity levels.
- Designed and introduced leadership development, coaching and team management model, resulting in promotion of employees into increased levels of responsibility.
- Recruited and hired top performers to add talent and value to department.
- Performed statistical analyses to gather data for operational and forecast team needs.
- Cross-trained existing employees to maximize team agility and performance.
- Onboarded new temps by entering employee information into systems
Utilization Review Specialist
1 Year 5 Months- Evaluated medical guidelines and benefit coverage to determine appropriateness of services.
- served as subject matter resource providing medical claims review information.
- Executed medical underwriting and medical claims reviews independently, ensuring timely completion.
- Validated medical necessity and service authorization compliance through clinical documentation review.
Research Analyst
2 Years 8 Months- Analyzed statistical data using both modern and traditional methods.
- Gathered, arranged and corrected research data to create representative graphs and charts highlighting results for presentations.
- Supported design and implementation of survey instruments such as telephone questionnaires to obtain study information.
Education
Master of Science - Health Care Administration
Bachelor of Science - Nursing
Skills
Expenditure Authorization
Financial Operations Oversight
Data Analysis
In-service Programs
Financial Reporting Coordination
Employee Recruitment and Hiring
Critical Thinking
Verbal and Written Communication
Policy and Program Development
Employee Supervision
Employee Performance Evaluations
Decision Making
Time Management
Process Implementation
Interdepartmental Functions Coordination
Problem Resolution
Certification
- Licensed RN - 1980
Timeline
Manager -Clinical Medical Review
CareFirst
09.2011 - 06.2021Read More
Clinical Review Supervisor
CareFirst
05.2000 - 09.2011Read More
Utilization Review Specialist
Interim Health Care
12.1994 - 05.1996Read More
Research Analyst
Social And Scientific System
02.1992 - 10.1994Read More
Central Michigan University
Master of Science from Health Care Administration
Read More
North Carolina Central University
Bachelor of Science from Nursing
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