Shelly Cates
Chicago,USA
Summary
Demonstrates strong analytical, communication, and teamwork skills, with proven ability to quickly adapt to new environments. Eager to contribute to team success and further develop professional skills. Brings positive attitude and commitment to continuous learning and growth.
Overview
13
13
years of professional experience
Work History
PA DM SPECIALIST 1
Cotiviti
05.2023 - Current
- Maintained in-depth CMS and NAIC compliance knowledge to accurately determine order of liability, contributing to reduction of adjudication errors.
- Perform data mining, claim adjudication, contract compliance, provider billing and duplicate payment reviews to resolve discrepancies.
- Record overpayments in Cotiviti systems following standard procedures to ensure accurate financial recovery.
- Use Cotiviti Recovery Management System to complete audits accurately and meet client-specific tool requirements.
- Maintain in-depth CMS and NAIC compliance knowledge to determine correct order of liability and reduce adjudication errors.
- Exceeded productivity and quality targets for auditing, ensuring consistent attendance and meeting project volume goals.
SUPERVISOR REFERRAL SERVICES
Illinicare/Aetna Better Health/ CVS
06.2018 - 05.2023
- Conducted departmental quality audits and educated team on process workflow improvements to enhance service delivery.
- Assisted senior leadership with budgets and forecasts for strategic planning and key initiatives.
- Coordinate with departments associated with the lines of business within the Utilization Management department.
- Monitor utilization of medical services to ensure cost effective use of medical resources.
- Offered direction and gave constructive feedback to motivate team members.
- Completed research on complex problems and resolved issues in a timely manner.
LEAD REFERRAL SPECIALIST
Centene/Illinicare
06.2015 - 06.2018
- Conducted monthly audits for Referral Specialists to ensure compliance with audit guidelines.
- Maintained all reports and documents related to staff audits.
- Monitored calls for quality assurance among Referral Specialist staff. for all Referral Specialist staff.
- Processing of the CRM prior authorization queue.
- Daily real-time monitoring of queue/agent status in CMS system.
- Bi-weekly reporting of staff login/out times based on current RS schedules.
- Trained new hires and provided up-training for existing staff.
- Create schedule for training and precepting with current staff and new hires.
REFERRAL SPECIALIST
Centene/Illinicare
11.2013 - 06.2015
- Initiated authorization requests for input/output services, researching claims inquiries to ensure compliance with departmental responsibilities.
- Process referrals and refer to Case Managers.
- Conduct eligibility screenings to determine program qualification.
- Enter authorizations in the system.
- Entered authorizations in the system, maintaining accurate records to support efficient service delivery.
Education
HIGH SCHOOL DIPLOMA - English
John F Kennedy
Chicago, IL01.1990
Skills
- Process improvement
- Troubleshooting
- Problem solving
- Data analysis
- Workflow optimization
- Customer service
Timeline
PA DM SPECIALIST 1
Cotiviti
05.2023 - Current
SUPERVISOR REFERRAL SERVICES
Illinicare/Aetna Better Health/ CVS
06.2018 - 05.2023
LEAD REFERRAL SPECIALIST
Centene/Illinicare
06.2015 - 06.2018
REFERRAL SPECIALIST
Centene/Illinicare
11.2013 - 06.2015
HIGH SCHOOL DIPLOMA - English
John F Kennedy