Summary
Overview
Work History
Education
Skills
Timeline
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Shirley Kelly

Riverside,CA

Summary

Multi-line Claims Supervisor dedicated to quality investigation, adjustment and supervision of diverse cases. Blends strategic planning and leadership strengths to establish top-performing claims departments. Trains and mentors staff, optimizing compliance with policies, procedures and applicable laws. Facilitates positive and productive interactions between workers, leaders and union representatives. Successful background reaching consensus and smoothing relations to maximize success of negotiations.

Overview

9
9
years of professional experience

Work History

Grievance Appeals Specialist

Newquest LLC
09.2023 - 05.2024
  • Enhanced grievance appeals efficiency by streamlining processes and implementing best practices.
  • Provided training and mentorship to new team members, fostering a collaborative work environment focused on continuous improvement.
  • Navigated through multiple systems to effectively Investigate grievances to find route cause
  • Created resolution letters for each grievance with standard language
  • Familiar with Medicare part D & C and Dental grievances
  • Connected with internal and external vendors through subtask and or email to ensure accurate investigation on grievances

Claims Supervisor

Humana
04.2021 - 03.2023
  • Maintained knowledge of benefits claim processing, claims principles, medical terminology, and procedures and HIPAA regulations.
  • Verified patient insurance coverage and benefits for medical claims.
  • Managed large volume of medical claims on daily basis.
  • Researched and resolved complex medical claims issues to support timely processing.
  • Monitored and updated claims status in claims processing system.
  • Followed up on denied claims to verify timely patient payment and resolution.

Appeals & Grievances Coordinator

Roche
02.2018 - 02.2021
  • Processed and finalized appeals and grievances within agreed-upon turnaround time.
  • Completed in-depth investigations into issues pertaining to discipline and grievance management and recommended strategies.
  • Remained knowledgeable regarding company policies and procedures and current developments within operational departments.
  • Submitted verbal and written notification to members and providers.
  • Research claims and appeals and grievances using company systems to determine appeals and grievance outcomes.

Customer Service Representative

Los Angeles Youth Network
11.2015 - 01.2018
  • Maintained confidential patient, employee and company information in compliance with company policies and regulatory requirements.
  • Gathered information, assessed and fulfilled callers' needs and educated on important policies and procedures.
  • Identified, analyzed and researched systemic issues and made recommendations for resolution.
  • Maintained designated portfolio of customer accounts by contacting customers behind on payment obligations.
  • Verified insurance eligibility and coverage for patients.

Education

Associate of Science - Computer Engineering

Riverside City College
08.2024

Skills

  • Reading Comprehension
  • Claims Investigation and Research
  • Claims Understanding
  • Claim Validity Determination
  • Claims Analysis
  • MS Office Suite
  • Conflict Resolution Tactics
  • Leadership Skills
  • Active Listening
  • Organized
  • Excellent Multitasking Capability
  • letter writing
  • Issue Identification

Timeline

Grievance Appeals Specialist

Newquest LLC
09.2023 - 05.2024

Claims Supervisor

Humana
04.2021 - 03.2023

Appeals & Grievances Coordinator

Roche
02.2018 - 02.2021

Customer Service Representative

Los Angeles Youth Network
11.2015 - 01.2018

Associate of Science - Computer Engineering

Riverside City College

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Shirley Kelly