Senior Claims & Provider Operations Specialist

Shantelle WhitePeoples

***********************@*****.*** 843-***-****

Senior Healthcare Claims & Provider Operations Specialist Remote Medicare Medicaid Commercial Marketplace

PROFILE

Senior healthcare operations professional with 12+ years of experience in claims processing, 19+ years of customer service, provider relations, escalation management, and multi-payer revenue cycle operations. Extensive expertise in Medicare, Medicaid, Commercial, and Marketplace plans with proven ability to resolve complex provider disputes, reduce claim denials, and ensure regulatory compliance. Strong background in institutional and professional claims, DME prior authorizations, and escalation oversight in remote environments.

CORE COMPETENCIES

Claims and Benefits explanation Provider Dispute Resolution Escalation & Root Cause Analysis COB & Enrollment Review CMS Compliance Remote Workforce Leadership EXPERIENCE

Broadpath Healthcare Solutions-Subject Matter Expert(WFH) — Sept2025 -current

•Serve as escalation specialist for complex member and provider claims inquiries.

•Interpret plan benefits, COB coordination, premium billing, and eligibility determinations. •Provide SME guidance on multi-payer policies and CMS regulatory compliance. •Support high-volume resolution while maintaining quality and accuracy standards..

BCBS -Claims processor-Surfside SC — March2025-Sept2025

•Processed institutional and professional claims in accordance with payer guidelines.

•Reviewed deferrals, split claims, and DME prior authorizations (CMN). •Ensured clean claim submission and compliance with timely filing requirements. •Resolved claim discrepancies to reduce denials and rework.

UHG-Senior Customer Service Rep — June2023-Oct2024(WFH)

•Managed enrollment and benefit inquiries for commercial and student health plans.

•Investigated complex claim escalations and payment discrepancies. •Collaborated with providers and internal departments to resolve billing disputes. Broadpath Healthcare Solutions-Operations Supervisor(WFH) — Sept2019-Aug2023

•Led team of agents and SMEs supporting benefits, claims, billing, and provider disputes. •Oversaw escalation resolution for Medicare, Medicaid, Commercial and Marketplace plans. •Conducted audits and quality reviews to ensure regulatory compliance. •Trained and coached staff on claims workflows and CMS policies. EDUCATION & CERTIFICATION

-Allison – Medical billing and coding ICD 10& 11 certification (completed), Medical Billing & Coding Diploma (In Progress)

-Benedict College

-Tricare Claims Processor Certification

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