Summary
Overview
Work History
Education
Skills
Timeline
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Sheniece Jones

Romeoville,IL

Summary

An expert client relationship specialist with a creative mindset, highly motivated, and quick to master any industry’s specifics. Eager and committed to helping organizations achieve its goals and objectives. An agile learner with a gift for innovation, team building and proficient in fostering and sustaining strong, positive work relationships with internal and external stakeholders.

Overview

10
10
years of professional experience

Work History

Refund Recovery Specialist

CHANGE HEALTHCARE
01.2018 - 05.2023
  • Manage and execute claim recoveries on various statements including pharmaceutical and high cost drug claims
  • Acted as a liaison between the provider and the insurance company that helped to facilitate payments and, in some cases, negotiate settlements
  • Professionally and effectively communicated with providers and hospitals to provide refund and payment information
  • Consistently managed a monthly refund intake averaging over $600,000, with multiple months surpassing $1,000,000
  • Ensure adherence to state policies, reimbursement policies, and contract compliance as it pertains to the refund recovery process.
  • Successfully handled over 350 provider accounts, ensuring compliance with the daily requirement of at least 100 case touches

Provider Services Representative and Network Account Manager

Molina Healthcare OF ILLINOIS
01.2016 - 01.2017
  • Managed more than 20 provider networks with each network consisting of over 50 providers, maintaining a high concentration on SNF, LTC, DME, Hospice, and Home Health providers in the ancillary network statewide
  • Educated physicians/office staff regarding Claims, Prior Authorization, HCC/Quality Measures, Contracting, Case Management and Web Portal Access
  • Developed and facilitated Joint Operational Committee (JOC) meetings with internal and external leadership to promote change and create problem resolution blueprints
  • Conducted site visits to educate and support Molina’s ancillary provider network on billing guidelines, HEDIS updates and state mandated changes
  • Maintained provider data integrity including monitoring provider credentialing, HEDIS Metrics, location/provider additions and terminations, demographic updates, and provider terminations
  • Systematically reviewed and cleaned up an average of 350 claims per provider
  • Acted as a liaison between the provider and the insurance company that helped to facilitate payments and, in some cases, negotiate settlements

Care Review Processor; Utilization Management

Molina Healthcare OF ILLINOIS
01.2013 - 01.2016
  • Subject Matter Expert for the Utilization Management Communications team
  • Communicated effectively with over 150 providers per day via incoming calls and emails
  • Trained new employees on department policies and procedures
  • Developed training materials on departmental workflows, policies, and procedures
  • Collaborated with coworkers, management, and other departments to help coordinate provider solutions in an effective and timely manner
  • Maintained departmental email boxes by researching inquiries and following up with providers

Education

Accounting

Concordia University
Mequon, WI

High School Diploma -

Downers Grove South High School
Downers Grove, IL

Skills

  • Problem Resolution
  • Customer Relations
  • Proficient at settlement negotiations both internally and externally
  • Detail Oriented
  • Communication Expert
  • Competent in Claims Review and Analysis
  • Adaptable in Evolving Environments
  • Proficient in AP & AR Processes
  • Skilled in the Coordination of Medicare Coverage and Claim Processes
  • Superior Analytical Skills
  • Network Management

Timeline

Refund Recovery Specialist

CHANGE HEALTHCARE
01.2018 - 05.2023

Provider Services Representative and Network Account Manager

Molina Healthcare OF ILLINOIS
01.2016 - 01.2017

Care Review Processor; Utilization Management

Molina Healthcare OF ILLINOIS
01.2013 - 01.2016

Accounting

Concordia University

High School Diploma -

Downers Grove South High School

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Sheniece Jones