Resolution Specialist Quality Auditor
Resume:
SHADIRAH RICHARDSON
E: ******************@*****.*** M: 908-***-**** Hillside, NJ
PROFESSIONAL SUMMARY
Results-driven professional with progressive experience in auditing, compliance, and risk management. Dynamic leader with a
proven history of championing employee development strategies that align with operational objectives. Highly analytical with a
proven history of leading process improvement initiatives that improve operational efficiency and mitigate operational risks.
Excellent oral and written communicator with demonstrated experience in explaining findings, conclusions, and recommendations
through informal and formal briefings. Proficient in the use of computer systems and applications, including Microsoft Office Suite
tools (Word, Excel, PowerPoint).
© Compliance © Training Development © Process Mapping
© Quality Assurance © Process Improvement © Report Preparation
PROFESSIONAL EXPERIENCE
Healthfirst Inc. New York, NY
Senior Quality Auditor — Provider Relations 12/2014 - Present
© Successfully support the quality assurance, risk management, and employee development goals of the company by leading
full-scale internal control audits with a focus on identifying trends in errors to implement improvement strategies.
© Effectively provide leadership to the audit team through one-on-one coaching, formal observations, and refresher training
initiatives; evaluate individual/team performance by citing errors to address areas of concern and reduce repetitional risks.
© Strategically minimize operational risks and compliance by completing dozens of internal audits across various processes
related to provider operations with a focus on providing data-driven actionable recommendations to prevent future errors.
© Independently prepare business-impacting reports and data regarding individual and team monthly, quarterly, YTD
percentages, and error trends for leadership review while proactively building measures aligned with business needs.
© Maximized department productivity and employee development efforts by creating various deliverables (training
documents, job aids, tip sheets) for the audit team to improve employee understanding of internal processes and audit
workflows.
© Strengthen compliance and audit quality efforts by facilitating and leading meetings with the leadership team and provider
operations department to discuss complex organizational issues and corrective actions to maintain a 98% audit score.
© Subject matter expert (SME) for new audit tasks for the Credentialing Department and Disclosure and Ownership (DOO)
process.
© Train and support new hires; maintain supportive relationships with staff through coaching and collaboration methods.
Magellan Health Services Parsippany, NJ
Quality Auditor -- Provider Relations 01/2011 - 07/2014
© Promoted to this position to contribute to the quality assurance and compliance goals of the organization by completing
audits and providing solutions-driven support to the client (Horizon Blue Cross Blue Shield) in reducing errors and risks.
© Independently completed an average of 15 audits per day; reviewed appeals, complaints, and clinical files/letters composed
by Horizon Blue Cross Blue Shield employees for accuracy and compliance with organizational policies/federal regulations.
© Strategically provided direct coaching to Medical Clinicians employed by the client to discuss audit scores, cite errors, and
provide strategies for improvement while providing training resources and job aids to reduce the occurrence of errors.
© Maximized the effectiveness of the audit process by creating training tools (manuals, tip sheets, process maps) to educate
end-users on completing the audit process, quality review expectations, and performance goals.
© Routinely reviewed SOPs, trends in quality assurance, and compliance audits to report findings to leadership during monthly
trend meetings; provided input on new and existing risk indicators to identify and correct workflow inefficiencies.
Magellan Health Services Parsippany, NJ
Claims Resolution Specialist 10/2008 — 12/2010
Effectively supported the compliance, claims management, and productivity goals of the organization by resolving claims
issues on behalf of the client (Horizon Blue Cross Blue Shield) in accordance with internal policies and procedures.
© Independently managed both claims processing and adjusting, averaging 40 medical claims related to mental health and
substance abuse; routinely evaluated claims data (dates of service, diagnosis codes, benefits) to achieve approval or denial.
© Strategically processed claims with a high-level quality and in accordance with the current claims payment policy and terms
of the customer/provider contractual agreements while documenting all actions taken within the internal system.
© Routinely communicated with claims submitters to perform detailed claims analysis to communicate the reason for claims
denials or to identify claims issues and perform claims adjudication and complex claims adjustments.
Precisely completed appropriate claims paperwork, documentation, and system entry while providing a detailed
reconciliation finding and escalate any trends or items.
SOFTWARE/TECHNOLOGICAL PROFICIENCY
Type 70+ wpm Microsoft Word Excel PowerPoint Nasco Q-blue SHIPS for state employees UCSW Horizon systems
Tableu Pivot Table PLM Macess MHS
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