Shirley Doll
Maineville
Summary
Effective Medical Claims Processor and Auditor with a strong background in verifying insurance benefits, pharmacy prior authorizations and client services. Possesses strong multitasking and time management abilities.
Analytical professional in the insurance investigation field known for high productivity and efficient task completion. Skilled in claim evaluation, fraud detection, and regulatory compliance, ensuring thorough and accurate case handling. Excel in communication, problem-solving, and decision-making, leveraging these soft skills to navigate complex cases effectively and deliver optimal outcomes.
Overview
12
12
years of professional experience
Work History
Level II medical claims auditor
Elevance Health
Mason
03.2023 - 05.2025
- Review and analyze medical claims for accuracy, compliance, and fraud prevention.
- Identifying discrepancies, ensuring adherence to company policies and regulations.
- Preparing and presenting audit reports to management, highlighting findings and recommending solutions.
- Identifying process improvements to streamline claims processing to reduce errors.
Level III Medical claims processor
Elevance Health
Mason
06.2018 - 02.2023
- Evaluated accuracy and quality of data entered into agency management system.
- Responded to correspondence from insurance companies.
- Paid or denied medical claims based upon established claims processing criteria.
- Maintained confidentiality of patient finances, records and health statuses.
Client Services Specialist
Express Scripts Inc
Mason
05.2016 - 03.2018
- Cultivated long-lasting client relationships based on trust and solid understanding of business needs.
- Effective liaison between clients and internal departments.
- Promoted superior experience by addressing clients concerns and resolving problems swiftly.
Prior Authorization Representative
Express Scripts Inc
Mason
02.2013 - 05.2016
- Processed new medication and refill requests when authorizations are required.
- Verified eligibility and compliance with authorization requirements for service providers.
- Fielded telephone inquiries on authorization details from medical staff.
Education
High School Diploma -
Rowan county senior high school
Morehead, KyPhlebotomy -
Warren county carrier center
Skills
- Claims auditing
- Fraud detection
- Data verification
- Claims processing
- Quality assurance
- Client communication
- Attention to detail
- Time management
- Team collaboration
- Compliance and regulations
- Exemplary communication skills
- Policy interpretation
- Liability and coverage
- Healthcare procedures
Timeline
Level II medical claims auditor
Elevance Health
03.2023 - 05.2025
Level III Medical claims processor
Elevance Health
06.2018 - 02.2023
Client Services Specialist
Express Scripts Inc
05.2016 - 03.2018
Prior Authorization Representative
Express Scripts Inc
02.2013 - 05.2016
High School Diploma -
Rowan county senior high school
Phlebotomy -
Warren county carrier center