Shuron McClinton
Crowell,TX
Summary
Crowley, TX Hard working individual with many years of processing Healthcare claims using Qnxt application. Seeking a position where my skills can be displayed, recognized and also be an asset to the company. Also, seeking a great career that has opportunities for advancement. Authorized to work in the US for any employer Experienced Auditor focused on improving business compliance, workflow and processes through detailed audits and optimization recommendations. Successful track record of fully evaluating information, structures and procedures and initiating corrective actions.
Overview
15
15
years of professional experience
Work History
QNXT SQL AUDITOR
Catalyst Solutions
2023.05 - Current
- Performs routine and moderately complex audits on paper and electronic claims for payment integrity in alignment with regulatory standards and timelines, business policy, contract, appropriate coding, and system configuration with the ability to extract and audit exception audit reports
- Researches claim processing problems and errors to determine their origin and appropriate resolution
- Prepare reports and summarize observations for management summarizing observations and recommendations
- Participates in communication with management regarding trends to improve claims processing accuracy and documented business rules for incorporation into training programs, policies, and procedures
- Identifies and escalates issues related to instructional material that is inaccurate, unclear, or contains gaps
- Provides recommendations for correction of this material
- Confers with management to assess training needs in response to changes in policies, procedures, regulations, and technologies
- Performs special project audits and reviews.
Claims Adjustment & Dispute Specialist
Catalyst Solutions
2022.11 - 2023.05
- Reviews medical records/case file, writes a reconsideration/dispute resolution decision that is clear, concise, and impartial and supports the determination made, and documents review
- Makes sound, independent decisions based on medical evidence in accordance with statutes, regulation, rulings, and policy
- Responds to and ensures that all appeal/dispute issues raised by the beneficiary/patient, representative, and provider/supplier have been addressed
- Provides a fair and impartial decision based on current evidence, regulations, policies, and procedures
- Conducts research using online federal regulations, contract policy, standards of medical practice, contract manuals, coverage issues manuals, medical literature, and other related resources to complete an accurate and well-supported decision.
Claims Examiner III
Molina Healthcare Inc
WFH , CA
2022.01 - 2022.11
- Performs root cause analysis of claims/encounters processing and submission issues; develops recommendations based on data and industry knowledge
- Collaborates across departments to design and implement systems changes to meet encounter data processing and submission goals
- Develops various reports (i.e
- Exception reports, standard reports, and performance reports) and distributes them to appropriate departments for error resolution, follow-up and performance monitoring
- Participates in a workgroup to resolve encountered data and process issues
- Monitors provider compliance with policies, procedures, and regulations for the coding of encounters.
Claims Senior Analyst
Cigna Healthspring Medicaid
Bedford , TX
2018.11 - 2021.12
- Analyzing and processing claims transactions in accordance with plan provisions
- Adjudicating claims based on your knowledge of covered benefits, insurance and provider contracts
- Determining plan liability as well as diversion and recovery activity for claims
- Ensuring customer satisfaction and strive to meet service standards
- Collaborating with management or other team members as appropriate to proactively address service issues and concerns
- Working with staff to resolve questions
- Working with team lead and audit team on audit findings.
Forklift Operator
Amazon Fullfillment
Coppell , TX
2014.11 - 2018.02
- Pulled and prepared product for shipment in an efficient manner to meet customer service standards
- Maintained appropriate records, data entry and reports to guarantee product control and safety
- Used computers and WMS computer systems, including RF handheld scanners to enter data and process information for accurate records
- Performed daily safety and maintenance checks of lift vehicles
- Identified and reported faulty equipment damaged, and safety concerns to Supervisor immediately
- Maintain forklift by troubleshooting breakdowns, performing preventive maintenance and performing routine pre and post inspections.
Auditor
LSG Sky Chefs
Dallas , TX
2012.06 - 2014.10
- Accurately counted all eating utensils before departure
- Inspected all utensils for cleanliness or damages and replaced them if needed
- Greeted all staff and passengers in a professional manner
- Kept thorough notes of inventory and if count was off made necessary changes.
Assistant Manager
Dollar General Store
Pine Bluff , AR
2009.10 - 2012.06
- Managed a group of associates and staff members
- Maintained all operations within the store
- Opened and closed the store at the beginning and end of shifts
- Performed official money count every shift
- Upheld a high standard of customer service
- Managed daily reports of transactions
- Ordered and stocked store merchandise
Education
High School Diploma - undefined
Watson Chapel High School
1998
Skills
- SQL
- Claims
- Understanding the procedures and forms used for medical billing
- Verbal communication
- Speaking clearly, correctly, and concisely
- Protecting patient privacy
- Understanding privacy rules and regulations associated with patient records
- Maintaining data integrity by detecting errors
Timeline
QNXT SQL AUDITOR
Catalyst Solutions
2023.05 - Current
Claims Adjustment & Dispute Specialist
Catalyst Solutions
2022.11 - 2023.05
Claims Examiner III
Molina Healthcare Inc
2022.01 - 2022.11
Claims Senior Analyst
Cigna Healthspring Medicaid
2018.11 - 2021.12
Forklift Operator
Amazon Fullfillment
2014.11 - 2018.02
Auditor
LSG Sky Chefs
2012.06 - 2014.10
Assistant Manager
Dollar General Store
2009.10 - 2012.06
High School Diploma - undefined
Watson Chapel High School
Similar Profiles
Debra HolmesDebra Holmes
Claims Processor at Catalyst SolutionsClaims Processor at Catalyst Solutions
Yvette JonesYvette Jones
BENEFIT CONFIGURATION ANALYST at Catalyst SolutionsBENEFIT CONFIGURATION ANALYST at Catalyst Solutions
Sharon NelsonSharon Nelson
Claims Supervisor at Catalyst SolutionsClaims Supervisor at Catalyst Solutions