Summary
Overview
Work History
Education
Skills
Timeline
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Sherwyn Moore

Claymont,DE

Summary

Seasoned Specialist offering 27 years of comprehensive experience interpreting and implementing quality assurance standards and investigating compliance and non-compliance contract claim issues. Practiced and knowledgeable professional possessing excellent problem solving and analytical skills paired with strong knowledge of QA terms, and cotract claim methodologies

Overview

37
37
years of professional experience

Work History

Sr. Specialist (TL), Payment Accuracy

Cotiviti Healthcare
Blue Bell, PA
09.2015 - 10.2022
  • Provided technical support and guidance to junior specialists.
  • Developed, maintained, and implemented strategic plans for projects.
  • Created detailed reports analyzing project performance data
  • Coordinated with other departments to ensure successful completion of projects.
  • Analyzed complex problems and identified effective solutions.
  • Reviewed processes and procedures to identify areas of improvement.
  • Created documents detailing standard operating procedures.
  • Facilitated brainstorming sessions among teams to generate innovative ideas.
  • Built team of successful Specialists by training on daily tasks and coaching on best practices.
  • Collaborated closely with upper management to develop corporate vision and roll out initiatives to meet goals.
  • Solved technical issues by troubleshooting, resolving and documenting service tickets
  • Identified areas requiring improvement, implementing new workflows to reduce task micromanagement
  • Monthly forecasting
  • Monthly one on one's auditors

Specialist II, Payment Accuracy

Cotiviti Healthcare
Blue Bell , PA
03.2012 - 09.2015
  • Identifying and defining issues within standard reports.
  • Develop report criteria, analyzing medium and complex reports.
  • Identify and validate over and under payments of claims
  • Perform quality assurance for audit team
  • Work with IT to increase efficiency of tools and reporting

Specialist I, Payment Accuracy

Cotiviti Healthcare
Blue Bell, PA
08.2010 - 03.2012
  • Data mining
  • Work moderate complexity reports
  • Identify incorrect deductions
  • Maintain standard level of quality set by the audit
  • Contribute to decisions on audit work performed

Quality Business Analyst

Independence Blue Cross
Philadelphia, PA
03.2007 - 08.2010
  • Conducted internal audits to measure adherence to established QA standards.
  • Used quality monitoring system to compile and track individual and team performance.
  • Communicated regularly with management to discuss quality trends.
  • Trained and led staff on proper QA standards.
  • Recommended improvements to systems and procedures for increased productivity.

Claims Specialist

Independence Blue Cross
Philadelphia, PA
09.2000 - 03.2007
  • Perform hospital accounts receivable analyst and research unresolved claims
  • Provide onsite claim support for multiple providers
  • Investigated complex or high-value claims to identify discrepancies.
  • Reviewed and analyzed insurance claims to determine validity, completeness, accuracy, and eligibility for payment.

Claims Processing Unit Leader

Independence Blue Cross
Philadelphia, PA
05.1997 - 09.2000
  • Monitored team performance to identify areas for improvement.
  • Provided guidance on best practices in order to enhance operational efficiency.
  • Assigned tasks according to individual abilities and strengths of employees.
  • Evaluated employee performance against established metrics and provided feedback accordingly.
  • Coordinated closely with upper management to ensure that goals were met efficiently.

Claims Processor

Independence Blue Cross
Philadelphia, PA
05.1995 - 05.1997
  • Reviewed and verified insurance policy information to assess coverage and determine appropriate claims processing procedures.
  • Processed a high volume of incoming claims in accordance with established policies and procedures.
  • Function as backup Unit Leader
  • Performed additional duties as requested by management team.

Clerical Support

General Accident Insurance
Philadelphia, PA
08.1989 - 12.1994
  • Entered data into spreadsheets and databases accurately.
  • Conducted office inventory checks and requested restock of supplies.
  • Organized filing systems for documents, records and other materials.

Clerk

W.I.C
03.1986 - 08.1989
  • Responsible for determining participants program eligibility
  • Maintain inventory
  • Establish relationships with vendors

Education

Bachelor of Science - Business Administration

Gwynedd Mercy University
Gwynedd Valley, PA
05.2010

Associate of Applied Science - Medical Laboratory Technology

McCarries Schol of Health Science
Philadelphia, PA
12.1984

Skills

  • Teamwork and Collaboration
  • Adaptability
  • Quality Assurance
  • Professionalism
  • Problem-Solving
  • Decision-Making
  • Active Listening
  • Analytical Thinking
  • Microsoft Office

Timeline

Sr. Specialist (TL), Payment Accuracy

Cotiviti Healthcare
09.2015 - 10.2022

Specialist II, Payment Accuracy

Cotiviti Healthcare
03.2012 - 09.2015

Specialist I, Payment Accuracy

Cotiviti Healthcare
08.2010 - 03.2012

Quality Business Analyst

Independence Blue Cross
03.2007 - 08.2010

Claims Specialist

Independence Blue Cross
09.2000 - 03.2007

Claims Processing Unit Leader

Independence Blue Cross
05.1997 - 09.2000

Claims Processor

Independence Blue Cross
05.1995 - 05.1997

Clerical Support

General Accident Insurance
08.1989 - 12.1994

Clerk

W.I.C
03.1986 - 08.1989

Bachelor of Science - Business Administration

Gwynedd Mercy University

Associate of Applied Science - Medical Laboratory Technology

McCarries Schol of Health Science
Sherwyn Moore