Sherhonda Jones
Blythewood,SC
Summary
Focused healthcare professional with success and delivered unbiased perspective to solve disputes and make grievance and appeal determinations. Accomplished in collecting supporting information, drafting and reporting comprehensive documentation and leading agreements to resolve complex problems. Driven to strictly follow applicable laws and ethical procedures for all cases.
Overview
14
14
years of professional experience
Work History
Appeals Specialist
Aspirion Health Resources
06.2025 - Current
- Developed appeals functions, policies and procedures and documentation.
- Created, composed and maintained appeal response templates.
- Responded to attorney inquiries and litigation notices.
- Acted as a departmental resource on appeals matters.
- Calculated adjustments, premiums and refunds.
- Verified client information by analyzing existing evidence on file.
- Assured timely verification of insurance benefits prior to patient procedures or appointments.
- Manage 250 cases bringing in $150k per month.
Appeals Coordinator
Blue Cross Blue Shield of North Carolina
02.2025 - Current
- Developed appeals functions, policies and procedures and documentation.
- Coordinated with senior specialist to compose appeal responses.
- Responded to attorney inquiries and litigation notices.
- Acted as a departmental resource on appeals matters.
- Handled and processed 50 appeals cases per day.
Appeals Analyst
Allied Benefit Systems Inc.
04.2024 - 08.2024
- Followed department guidelines and tools to conduct reviews.
- Represented highest level of expertise required to respond to regulators and media inquiries.
- Analyzed and rendered determinations on assigned non-complex grievance and appeal issues.
- Utilized guidelines and review tools to conduct extensive research and analyze grievance and appeal issues.
Grievance and Appeal Coordinator
Magnit Global for Cigna Healthcare
11.2023 - 04.2024
- Entered data, generated reports, and produced tracking documents.
- Gathered and organized materials to support operations.
- Implemented project management techniques to overcome obstacles and increase team productivity.
- Resolved issues through active listening and open-ended questioning, escalating major problems to manager.
Grievance and Appeal Coordinator
Epitec for Blue Cross Blue Shield
06.2023 - 09.2023
- Performed audits and deep document reviews to verify compliance with applicable laws.
- Skilled at working independently and collaboratively in a team environment.
- Reviewed, analyzed and processed grievances and appeals.
- Analyzed and rendered determinations on assigned grievance and appeal issues.
- Utilized guidelines and review tools to conduct extensive research and analyze grievance and appeal issues.
- Followed department guidelines and tools to conduct reviews.
- Delivered exceptional customer service to policyholders by communicating important information and patiently listening to issues.
- Examined claims forms and other records to determine insurance coverage.
Grievance and Appeal Dispute Specialist
Emblem Health
08.2022 - 06.2023
- Kept up to date on industry information, system changes, network rules and compliance issues.
- Used sound judgment and available resources to make well-informed decisions for cases overturned or upheld.
- Interacted with providers, hospitals and persons of interest to obtain and review dispute information.
- Analyzed, researched and resolved 97 appeals per week with 100% accuracy.
- Prepared written opinions or decisions regarding 388 cases per month with 0 errors.
- Exercised leadership capabilities by successfully motivating and inspiring others.
- Demonstrated leadership skills in managing projects from concept to completion.
Medicare Enrollment Advisor
Express Consultants
01.2022 - 07.2022
- Handled questions, issues and provided detailed information on requirements, processes, and policies.
- Collected information and qualified beneficiaries for programs, services or plans.
- Ensured that applications were completed correctly and that the required supporting materials were provided.
- Provided guidance to beneficiaries about plans.
- Initiated enrollments and dis-enrollments.
Grievance and Appeal Analyst
MPF Federal for Optum Serve
11.2020 - 11.2021
- Represented highest level of expertise required to respond to regulators and media inquiries.
- Followed department guidelines and tools to conduct reviews.
- Utilized guidelines and review tools to conduct extensive research and analyze grievance and appeal issues.
- Analyzed and rendered 75 determinations on assigned complex grievance and appeal issues per day.
- Reviewed provider contracts and benefits to ascertain levels of coverage and determine whether appeals would be upheld or overturned.
Senior Advocate
Lt. Governor's Office
09.2011 - 11.2020
- Reviewed applications and screened beneficiaries to determine eligibility for medical and disability assistance.
- Discussed beneficiary grievances and provider appeals with Department of Health and Human Services to develop action plans, resolving 100% of complaints.
- Analyzed and collected data and information to evaluate improvements for beneficiary access to care.
- Connected underserved population to programs and community resources to help cover medical expenses through planned events at South Carolina State House, averaging 2000 attendees per event.
- Performed as primary liaison for beneficiaries, stakeholders, providers and partner organizations.
Education
Master's Degree - Criminal Justice
South University
Savannah, GA08-2011
Bachelor's Degree - Criminal Justice
Limestone College
Gaffney, SC05-2009
Skills
- Claims Investigation
- Benefit Review
- Dispute Resolution
- Evidence Gathering
- Service Improvement
- Decision Making
Timeline
Appeals Specialist
Aspirion Health Resources
06.2025 - Current
Appeals Coordinator
Blue Cross Blue Shield of North Carolina
02.2025 - Current
Appeals Analyst
Allied Benefit Systems Inc.
04.2024 - 08.2024
Grievance and Appeal Coordinator
Magnit Global for Cigna Healthcare
11.2023 - 04.2024
Grievance and Appeal Coordinator
Epitec for Blue Cross Blue Shield
06.2023 - 09.2023
Grievance and Appeal Dispute Specialist
Emblem Health
08.2022 - 06.2023
Medicare Enrollment Advisor
Express Consultants
01.2022 - 07.2022
Grievance and Appeal Analyst
MPF Federal for Optum Serve
11.2020 - 11.2021
Senior Advocate
Lt. Governor's Office
09.2011 - 11.2020
Master's Degree - Criminal Justice
South University
Bachelor's Degree - Criminal Justice
Limestone College