Sherida Johnson
Norfolk,VA
Summary
To obtain the hiring position that will enable me to utilize my strong claims researching/reviewing skills. Within the position I can help resolve issues and concerns providers may have regarding recoupments, overpayments and staying consistent with our policies and procedures. I work very well with members, providers and my peers; going forward I want to continue to make a positive contribution. Conscientious data specialist with several years maintaining digital integrity through full processing lifecycles. Superb talents in managing data intake, storage and transmission procedures. Strictly adherent to related regulations. Responsible provider of exceptional storage and delivery services for all forms of customer data.
Overview
16
16
years of professional experience
Work History
Network Data Specialist Sr
01.2020 - 07.2023
- Lead the department in problem identification, analysis, and resolution for multiple system provider database issues
- Participates in system testing and analysis in support of new functionality, new system processes, and business rules changes
- Validates the data to be housed on provider databases and ensure adherence to business and system requirements of customers as it pertains to contracting, network management and credentialing
- Researches and resolves complex exceptions and error reports, determine regional/cap/business indicators for multiple business areas to assure accurate reimbursement based on provider contract
- Determines training needs and train less experienced associates
- Reviewed and verified claims for the Audit team
- Assign NexGen Appeals out to the team as well as completed NexGen appeals.
Provider Data Management
07.2014 - 12.2019
- Maintained knowledge of state guidelines, regulations, and departmental policies and practices
- Updating provider’s demographic information from a Service Form, Roster or Contract
- Processing claims in Facets and macess
- Completed provider updates from the Escalation Tracker
- Completed NexGen and IRU items.
Customer Care Rep III (Provider Service Unit)
Amerigroup National Customer Care
Virginia Beach, VA
03.2012 - 01.2014
- Research and adjust all Medicaid, intermediate level claims transactions
- Accurately interprets and understands payment explanations, appeal outcomes and denials
- Sends information to providers via mail/fax (denial/approval letters, explanation of payments)
- Meets or exceeds established quality and production standards
- Reviews and responds to quality audits
- Consistently achieve all performance metrics
- Certified and skilled in Facets, Compass and Macess
- Utilize the medical agreement configurator to provide claim pricing details
- Assisted with the Virginia Market Project by researching claim processing according to the provider’s contract
- Researched pended/unresolved Provider Service unit issues sent to the Internal Resolution Unit for a resolution
- Assisted as an OJT (on the job training) SME for newly promoted/ hired associates Virginia Anthem team.
Customer Care Rep I
02.2007 - 03.2012
- Telephonic assistance to members, providers and vendors regarding eligibility, benefits, and authorization status
- Maintained knowledge of state guidelines, regulations, and departmental policies and practices
- Provided excellent customer experience through problem solving, resolutions and listening
- Interacted with providers and departments to resolve membership and credentialing issues
- Explained benefits/eligibility, enrollment procedures, and authorization/ referral status to callers
- Assisted as an OJT (on the job training) SME for newly promoted/hired associates.
PAA Provider Service
09.2010 - 03.2011
- Knowledge of researching malpractice sanctions by means of OIG/EPLS systems
- Input/verified authorization request for providers
- Provided comprehensive and precise explanation of benefits in order to ensure an understanding of policies regarding medical coverage
- Enter referral pre-certification and routed call/fax to RN for clinical component if needed.
Network Education Representative
07.2023
- Provides/coordinates provider training for claims and billing procedures, contract compliance, medical management, and pharmacy issues
- Promotes provider compliance with local/state/region/federal regulations through provider forums and training opportunities
- Facilities provider network by recruiting necessary PCP, Specialist, Ancillary, and Hospital providers and assisting Network Support, Contracting, and Credentialing associates to credential and maintain accurate provider contract data
- Ensures member access to care through network maintenance, telemedicine site support, and recruitment of culturally and linguistically appropriate providers, as appropriate.
Education
High School Diploma -
Norview High School
Norfolk, VA06-1997
Skills
- Technical proficiency in Microsoft Office Suite (Word, Excel, Outlook)
- Certified and skilled in Facets, Macess, NexGen, Macro, RAM, Quest Audit, Escalated Tracker, PCR, Salesforce, Contraxx
- Outlook to schedule meetings, status of tasks, keep executive’s calendars and contacts
- Expertise in multi-lined telephone systems, scanners, faxes, and copiers
- Possesses good work ethic and is keen to paying attention to detail
Objectivesummary
To obtain the hiring position that will enable me to utilize my strong claims researching/reviewing skills. Within the position I can help resolve issues and concerns providers may have regarding recoupments, overpayments and staying consistent with our policies and procedures. I work very well with members, providers and my peers; going forward I want to continue to make a positive contribution.
Timeline
Network Education Representative
07.2023
Network Data Specialist Sr
01.2020 - 07.2023
Provider Data Management
07.2014 - 12.2019
Customer Care Rep III (Provider Service Unit)
Amerigroup National Customer Care
03.2012 - 01.2014
PAA Provider Service
09.2010 - 03.2011
Customer Care Rep I
02.2007 - 03.2012
High School Diploma -
Norview High School
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