Shanta Allen

Murfreesboro, TN ***** 615-***-**** ad4gvf@r.postjobfree.com

COMPLIANCE SPECIALIST SENIOR ANALYST

Compliance Specialist Senior Analyst with a diverse background in claims operations, quality assurance and compliance, claim appeals, plan management, and provider network relations. Highly organized, effective leader and communicator dedicated to making operational and procedural improvements by creating valuable partnerships at all levels of the organization, including stakeholders, customers, clients, and providers. Expertise lies in utilizing advanced analytical tools and methodologies to extract valuable insights, optimize omni-channel lifecycle strategies, and streamline operational workflows. Dedicated to delivering innovative solutions that enhance organizational performance and drive measurable results in dynamic environments.

KEY SKILLS

Quality Assurance Appeals Trends Analysis Quality Improvement Problem Solving Communication Image One Time Management Prioritization Team Leadership Data Analysis Health Plan Policies Mentoring

PROFESSIONAL EXPERIENCE

CIGNA HEALTHCARE, Nashville, TN Franklin, TN January 2023 – Present

Compliance Specialist Senior Analyst (January 2023 – Present)

Manage the Group Core Medical certificate and policy language filings, subsequent language implementation activities, and IFP filing activity. Maintain positive working relationships with Legal and Regulatory partners as well as Product, Service Operations and Solutions Management teams.

Manage multiple form, rate, and binder filings in the SERFF system simultaneously.

Develop, write, and revise policy and certificate language.

Respond to insurance department objections and manage objections in accordance with established policies and procedures.

Negotiate directly with state regulators (involving Compliance, Government Affairs and supporting attorneys as appropriate).

Work collaboratively with Service Operations’ Language Release Team to initiate the process of moving filed and approved language into production.

Conduct regulatory research, review emerging legislation for applicability to impacted products and respond to questions relating to products, research, and emerging legislation.

Provide project management support and coordinate state filing activities, and triage the incoming work requests for Qualified Health Plan (QHP) Template.

Manager Supervisor Claims Operations Quality Assurance, (August 2011 – January 2023)

Performed compliance, operational, financial and information system audits to evaluate internal controls effectiveness, efficiency and confirm operations comply with federal, state, and contractual requirements.

Supported, monitored, and performed quality assurance for new products, or complex multi-products through claims, configuration and claims system updates to ensure completeness, accuracy, and timeliness.

Identified process improvements and works with leadership team to champion improvement, adoption, implementation, and execution of processes.

Assisted in the oversight of the management and maintenance of the policies and procedures for Risk Testing, Fraud Prevention, and Internal Controls.

Analyzed adequacy, reliability, and compliance of internal related controls, risk assessment process, and monitoring activities.

Managed audit activity, workload distribution and development/modifications as to accuracy and adherence of department standards and procedures. Provided input to the performance review process for Internal Auditors.

Shanta Allen 615-***-**** Page 2

Collaborated with outside auditing vendors by scheduling and attending meetings to coordinate required external audits within the organization.

Assisted in the audit processes through the preparation and distribution of requested information. Documents and archives all organizational information disclosed to external auditors. 4 years’ experience SSAE 16/SOC and SOX report (PWC, LBMC and Deloitte).

Provided support and input for specialized and in-depth projects as requested. Analyzes and retrieves data appropriate for requested projects. Proficiency with Healthcare terminology such as ICD10 Codes and Medical Abbreviations.

Senior Claims Appeal (March 2002 – August 2011)

Assessed the medical necessity and appropriateness of patient care and treatment on a case-by-case basis.

Worked in a fast-paced environment with frequently changing priorities, deadlines, and workloads.

Evaluated demands on time and establish and manage appropriate priorities.

Expanded knowledge base of current medical procedural terminology, diagnostic entities, and their complications.

EDUCATION

Paralegal Certification

Nashville Career College, Nashville, TN

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