SHANTERRA BRAYE

ad146g@r.postjobfree.com 678-***-**** Morrow, GA 30260

Summary:

Valued-oriented professional with an extensive background in customer service, and administrative duties. Front-line representative for my employer, servicing providers, members. Has served as a patient educator coordinator in the Medicaid Outreach and Education Department. The Medicaid Outbound Call (OBC) Program is a telephonic outreach program which targets HEDIS care gaps to increase member compliance rate and improve the effectiveness of other Quality interventions. Served as Clerk II for Butts County Health Department, duties include processing patients and data entry into various databases, processing payments and claims and verification of insurance. Used to act as an advocate for our Medicare members’ preventive health needs.

Education:

North Miami Beach High School - Miami, FL

Skills:

Members

Providers

Medical terminology

Medical billing

Reimbursement

Credentialing

Data Entry

Medicare

Medicaid

Insurance verification

Claims

Documentation review

Medical records

ICD-10

HEDIS

Microsoft Office

Multi-line Phone Systems and Computer Skills

Customer Service / Call Center

Professional Experience:

Molina Healthcare June 2023- October 2023

Provider Advocate

Member/Providers outreach/ closing hedis gaps.

Having extensive domain knowledge in MMIS, EPIC, EDI X12, HL7, HIPAA, ICD 10, System, Medicare and Medicaid, CMS Compliances/Regulations.

Strong knowledge of managed claims management process, Knowledge of Medicaid and Medicare Services. CMS, Health Assessment Systems, Hl7 Standards, HIPAA, PPACA.

Serve as conduit for provider issues that crossed multiple platforms and/or resulted from integrations; answered questions related to total affordability initiatives; participate in provider joint operation commission meetings with core providers.

Educate and train providers on Link platform.

Facilitate training programs including Lunch and Learn sessions, telephonic or in-person seminars; conduct new provider education sessions for hospitals, physician groups, FQHC's, and health departments. Educate providers on common billing practice errors, reimbursement policies, service model/drive adoption, and self service tools including Link and UHC Online.

Coordination of Services: Consulting, collaboration and client education for hospitals and physician offices. Resolved problems in contract management, billing and revenue, claims, Medicare and prescription drug issues (coverage, rates, frequency, documentation and Medco interface).

Meeting daily abstraction goals and maintaining a high abstraction accuracy percentage

Measure the quality and effectiveness of patient care delivered to their covered patient population.

Aerotek, Riverdale, GA Jul 2018 – Dec 2022

Provider Representative

Answer customer requests or inquiries concerning services, products, billing, claims, and reports problem areas.

Prepare field orders (e.g., turn-ons, turn-offs, transfers, meter sets and removals); update and maintain customer account information.

Responsible for reviewing and resolving member complaints and disputes and communicating resolution to members in accordance with the standards and requirements established by the Centers for Medicare and Medicaid.

Outreach to members who don't have a record of the designated services, effective capture of barriers and data collection, use of motivational interviewing skills to provide solutions to close the gap in care and providing best in class support to each member.

Ensures that every customer is treated professionally, with respect and all questions are thoroughly answered and/or triaged and responded to.

Educate provider practices on appropriate HEDIS Measures, medical record documentation guidelines, and HEDI ICD-10 CPT coding in accordance with State, Federal, and NCQA requirements.

Acts as an advocate for our Medicare members preventive health needs.

Collect effective data elements in the CRM tool to support medical record chasing for HEDIS medical record documentation and services.

Assist Members with commercial, Medicaid, and Medicare D prescription drug benefits with any questions related to their benefits. Including but not limited to, taking them through the next steps to obtain drugs that are not covered or have a restriction that may require a prior authorization. Inform the Member of the prior authorization and appeals process.

CSR for HEDIS, Care Gap, Risk Adjustment and miscellaneous outreach to both providers and members.

Research claims, documentation for leads to satisfy preventive healthcare measures missing from current charts.

Provide information related to outside assistance and other options.

Adhere to established policy, procedure and quality standards within service standards or metrics for work performed.

Track related work activity for business process reporting & workload management.

Respond to service policy, rate questions, and billing inquiries.

Butts County Health Department, Jackson, GA May 2016 – May 2018

Member Service Representative

Served as Clerk II for Butts County Health Department, duties include processing patients and data entry into various databases, processing payments and claims and verification of insurance.

Completed data entry and pulled analysis from various databases such as: M&M and GRITS.

Interviewed applicants, verified pregnancy and eligibility for Pregnancy Medicaid Program.

Scheduled and followed up on patient’s appointments.

Worked with each school to provide flu mist to all students in Butts County Schools as a part of the Flu Clinic.

Completed monthly review of balance statements, and invoice for self-pay clients.

Processed clients at the end of the appointment, including collecting payments and providing ASQ paperwork.

Processed all documents for immunizations.

Created, purged, and organized charts.

Answered all inbound calls.

Anthem, Inc. Kelly Service, Atlanta, GA Nov 2013 – Dec 2013

Patient Educator Coordinator

Served as a patient educator coordinator in the Medicaid Outreach and Education Department. The Medicaid Outbound Call (OBC) Program is a telephonic outreach program which targets HEDIS care gaps to increase member compliance rate and improve the effectiveness of other Quality interventions.

Assisted members with scheduling required appointments, selecting primary care physicians to help close care gaps.

Selected to participate to the New Jersey Medicaid/Diabetes Special Project Team I; assigned and completed 77 cases within 3 business days.

Selected to participate to the New Jersey Medicaid/Diabetes Special Project Team II; assigned and completed 867 cases within 20 business days.

Addressed the following care gaps: well child visit, well infant visit, adolescent well-care visit and breast and cervical cancer screenings, blood glucose screening, kidney disease monitoring and missing cholesterol screening.

Facilitated solutions for members when non-clinical care gaps were identified.

Collected alternate contact information for benefit of all key stakeholders in the company.

Facilitate 3-way calls with the member and their primary care physician or the 24-hour nurse information line.

Assisted members in overcoming barriers to access to care, including transportation and finance.

Butts County Health Department - Jackson, GA Jan 2012 – Dec 2013

Clerk II

Served as Clerk II for Butts County Health Department, duties include processing patients and data entry into various databases, processing payments and claims and verification of insurance.

Completed data entry and pulled analysis from various databases such as: M&M and GRITS.

Interviewed applicants, verified pregnancy and eligibility for Pregnancy Medicaid Program.

Scheduled and followed up on patient’s appointments.

Worked with each school to provide flu mist to all students in Butts County Schools as a part of the Flu Clinic.

Completed monthly review of balance statements, and invoice for self-pay clients.

Processed clients at the end of the appointment, including collecting payments and providing ASQ paperwork.

Processed all documents for immunizations.

Created, purged, and organized charts.

Answered all inbound calls.

Health Management Systems - Atlanta, GA Jan 2010 – Dec 2011

Case Worker

Served as a case worker for the Children’s Health Insurance Program

Reauthorization Act (CHIPRA) Department. The CHIPRA program was responsible for processing applications for Medicaid recipients for the state of Georgia.

Administered training for 80+ new hires with 100% graduation and certification rate which resulted in Process CHIPRA applications and approval or deny.

Completed and received inbound and outbound calls to and for Medicaid recipients.

Completed coordination and explanation of benefits for each recipient.

Verified medical premiums and coverage.

Educated potential and current members on policies & procedures.

Completed marketing, correspondence, faxes, and weekly reports as a part of production & checks process.

Assisted with the daily operations of program.

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