Shontay Sims
Summary
Detail-oriented professional with extensive experience in documentation review and care coordination. Proven ability to enhance collaboration with care managers and healthcare providers, ensuring timely and accurate patient support. Strong communication skills contribute to effective teamwork and improved patient outcomes.
Overview
11
11
years of professional experience
1
1
Certification
Work History
Analyst, Management
Aetna
01.2023 - Current
- Conducted the annual Health Risk survey to support needed identification for the members Individual plan of care
- Supported the member’s care coordination needs and drive solutions to address those needs.
- Adhered to case management and quality management processes in compliance with regulatory and accreditation guidelines and company policies.
- Completed care coordination activities delegated by the care manager within an established timeframe.
- Informed the assigned care manager of newly identified health/safety risks or service needs
- Processed dme request and all referrals for Social Determinants of Health
- Mailed resources to the members due to requested referrals of the member
- Provided referrals for Social determinants of health such as food, housing, utilities, clothing and transportation
- Processed dme request for members with coordination with their Primary care provider and dme companies
- Processed fax request to the provider for most current medication list
- Adapted to different state market changes and plan changes for care management activities
EAP Case Management Specialist
Progressive
01.2022 - Current
- Company Overview: EAP Case Management Specialist Remote
- Coordinated and oversee the implementation of the Employee Assistance Program, including developing policies, procedures, and resources.
- Conducted confidential assessments to determine the needs of employees seeking assistance.
- Provided short-term counseling and support services to employees, including crisis intervention and referral to external resources when necessary.
- Develop and deliver training programs and workshops to promote mental health awareness and stress management for employees.
- Maintain accurate and confidential records of EAP services provided, ensuring compliance with privacy laws and regulations.
- Collaborated with internal stakeholders, including HR, management, and supervisors, to ensure a holistic approach to employee well-being.
- Served as a knowledgeable resource for employees seeking information and guidance on mental health and wellness topics.
- Stayed up-to-date with current trends and best practices in the field of employee assistance programs and mental health support.
- Evaluated the effectiveness of the EAP through data analysis and feedback from employees, making recommendations for improvement as needed.
- Excellent interpersonal and communication skills, with the ability to empathize and remain non-judgmental when working with employees in distress.
- Strong knowledge of counseling principles and techniques, including crisis intervention and brief therapy approaches.
- Proficient in assessing and addressing a wide range of mental health concerns, such as stress, anxiety, depression, and substance abuse.
- Maintained confidentiality and adhere to professional ethical standards.
- Exceptional organizational and time management skills, with the ability to prioritize and multitask effectively.
- Strong problem-solving abilities, with the capacity to identify and address complex employee issues.
- Proficiency in using computer software and databases to maintain accurate records and generate reports.
- Knowledge of relevant legislation, regulations, and best practices related to employee assistance programs.
- EAP Case Management Specialist Remote
Senior Pharmacy Technician
Ornisi Pharmacy
12.2021 - 08.2024
- Company Overview: Remote
- Review accuracy and completeness of prior authorization information requested and ensures supporting documents are present and meet company set standards.
- Assisted with the completion of medical necessity documentation to expedite approvals and ensures that appropriate follow up is performed.
- Collaborates with other departments to assist in obtaining prior authorizations/appeals.
- Document insurance company interactions and all prior authorization information in system.
- Review insurance denials and submit appeals as permitted by payor.
- Enters re-authorizations into the portal and ensures accurate completion of re-authorization forms.
- Submits completed re-authorization forms to the appropriate insurance plans.
- Maintains log of all re-authorizations submitted.
- Follows up with the patient's insurance company or physician office by phone, email or spreadsheets on all submitted re-authorization for patient approval/denial status.
- Remote
Pharmacy Analyst Coordinator
BCBS IL
01.2019 - 12.2021
- Company Overview: Remote
- Research claims appeals and grievances using support systems to determine appeal and grievance outcomes.
- Requests and reviews medical records, notes, and/or detailed bills as appropriate; formulates conclusions per protocol and other business partners to determine response; assures timeliness and appropriateness of responses.
- Processed prior authorization request from providers and procedures.
- Responsible for meeting production standards set by the department.
- Apply contract language, benefits, and review of covered services.
- Prior authorization, answering calls, making calls to providing doctors.
- Assisting patients who need treatment requiring insurance carrier pre-authorization.
- Prepares appeal summaries, correspondence, and document findings. Include information on trends if requested.
- Composes all correspondence and appeal/dispute and or grievances information concisely and accurately, in accordance with regulatory requirements.
- Processed PBM and Majoy Medical Rx claims.
- Telephonic outreach to Members to improve health quality outcomes with clinical pharmacist.
- Provided outreach to providers for appeals updates.
- Assess and interpret member needs and requirements, triaging to a clinical pharmacist when appropriate.
- Assisted members with benefit questions.
- Assisted members with setting up new accounts with mail order pharmacy.
- Providing members with benefit information for prescription, dental, and vision inquiries.
- Research pa criteria request, triaged to clinical pharmacist.
- Prepares appeal summaries, correspondence, and document findings. Include information on trends if requested.
- Composes all correspondence and appeal/dispute and or grievances information concisely and accurately, in accordance with regulatory requirements.
- Remote
Pharmacy Technician- Patient Care Coordinator
Walgreens
02.2018 - 09.2020
- Company Overview: Remote
- Educating members regarding various Medicare Part D plans - how to choose a plan, how the plan pays benefits, etc.
- Review insurance coverage for pharmacies, doctor's offices, hospitals, members and other identified individuals/organizations.
- Accept new prescriptions from members, inquire about medication allergies and obtain address from patient.
- Make sure name and medical record numbers are accurate and legible.
- Inform Pharmacist immediately of any interactions flagged by the computer system for Pharmacist intervention.
- Updates patient records regarding medication allergies and disease states.
- Adjudicates prescription claims for payment in accordance with Plan provisions, policies and procedures.
- Identify and edit prescription entries due to changes or entry error.
- Assist members with problems related to co-pays, deductibles, premiums or other related issues.
- Process prior authorization request for patients medication via fax, email and telephone.
- Medicare and commercial insurance knowledge.
- ICD-9 & ICD-10 knowledge.
- Medical billing process for ambulatory services.
- Inputting proper codes and diagnoses before being sent to billing.
- Remote
Clinical Coordinator
Team Health
11.2016 - 01.2018
- Coordinating patient care plans by liaising with all necessary care providers and medical professions to ensure patient needs are met.
- Collect and input patient data, insurance information and financial information into computer system.
- Attend departmental meetings and stay up to date on all business initiatives related to the clinic.
- Collect and review referrals and pre-authorizations.
- Check eligibility and benefits verification for treatments, hospitalizations, and procedures.
- Review patient bills for accuracy and completeness, and obtain any missing information.
- Obtain referrals and pre-authorizations as required for procedures.
- Knowledge of current ICD-9 and CPT codes.
Prior Authorization /Intake Coordinator Technician
Sure Scripts
11.2015 - 11.2017
- Company Overview: Remote
- Work with payers and staff to obtain initial and ongoing authorizations for client services.
- Researching, correcting and re-submitting rejected/denied claims.
- Processed prior authorization request via fax, phone, and email request from hospital or clinic.
- Explained denial or approval of authorization request to patient or hospital liaison.
- Medical billing inquiries using ICD 10 codes with payers.
- Verifying medical insurance coverage and benefits for each patient.
- Scheduling appointments for consultations, tests, and procedures.
- Completing all admissions paperwork and entering it digitally.
- Answering phone and email inquiries.
- Addressing any patient complaints or concerns.
- Remote
Insurance Verification
Insurance Verification-Rev MD
10.2014 - 09.2015
- Updating patient insurance information and personal information.
- Medical billing and coding for ambulatory services.
- Contact insurance companies for verification of coverage.
- Verified and updated the correct mileage of services.
- Identifying commercial insurance, Medicaid, and Medicare Part B.
Education
Bachelor’s Degree - Human Services
Walden University
Minneapolis, MN11-2022
Skills
- Medical billing and coding
- ICD-10 and ICD-9 proficiency
- Documentation review
- Medical terminology
- Epic systems
- Insurance verification
- EMR systems expertise
- Patient care experience
- Human resources management
- HRIS knowledge
- Employment and labor law understanding
- Communication skills
- Recruitment strategies
- Microsoft Office proficiency
- Long-term care knowledge
- CPT coding expertise
- Medcompass familiarity
- Rx claim and Rx 30 systems
- Snap software proficiency
- Managed care organization plans knowledge
- Community and state plans understanding
- Dual eligibility plans expertise
- Medicare Advantage plans familiarity
- Payer database systems knowledge
- Care coordination skills
- Health risk assessment abilities
- Crisis intervention techniques
- Compliance adherence skills
- Social determinants support strategies
Certification
- Pharmacy Technician License
- Crisis Intervention
- Certified Wellness Coach
- Certified Pharmacy Technician
- Bachelor’s Degree in Human Services - Graduated
Timeline
Analyst, Management
Aetna
01.2023 - Current
EAP Case Management Specialist
Progressive
01.2022 - Current
Senior Pharmacy Technician
Ornisi Pharmacy
12.2021 - 08.2024
Pharmacy Analyst Coordinator
BCBS IL
01.2019 - 12.2021
Pharmacy Technician- Patient Care Coordinator
Walgreens
02.2018 - 09.2020
Clinical Coordinator
Team Health
11.2016 - 01.2018
Prior Authorization /Intake Coordinator Technician
Sure Scripts
11.2015 - 11.2017
Insurance Verification
Insurance Verification-Rev MD
10.2014 - 09.2015
Bachelor’s Degree - Human Services
Walden University
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