Daron Shealy
Columbus
Summary
I'm a disciplined individual skilled in collecting and verifying patient demographic and insurance information and preparing and maintaining medical records. Proficient in using medical terminology and classifying diagnostic procedures, treatments and medications. Dedicated to providing highest quality care to patients. Organized and dependable candidate successful at managing multiple priorities with a positive attitude. Willingness to take on added responsibilities to meet team goals.
Professional representative with robust experience and strong commitment to delivering exceptional results. Effective at collaborating within teams and adapting to changing needs to ensure reliability and success. Skilled in communication, problem-solving, and customer relations, with focus on achieving impactful outcomes. Valued for proactive approach, integrity, and ability to build lasting professional relationships.
Overview
7
7
years of professional experience
Work History
Risk Adjustment Representative2
Humana Inc
01.2021 - Current
- Ensure coding is accurate and properly supported by clinical documentation within the health record
- Follows state and federal regulations as well as internal policies and guidelines while analyzing coding information and medical records
- Develop super user capabilities in Epic applications and all other related information systems, tools, technologies, and processes; assist other employees as needed to ensure all tools are fully utilized to create an efficient and effective department
- Coordinates the HEDIS medical record review which includes ongoing review of records submitted by providers and the annual HEDIS medical record review
- Typically works on routine and patterned assignments
- Regularly exercises discretion and judgment in prioritizing requests and interpreting and adapting procedures, processes and techniques, and depth of knowledge of administrative
- Professional coding experience processes and organizational knowledge
- Coordinate and schedule meeting sessions required to ensure data requests and business
- Perform comprehensive2nd is rival or Piti records, prospective assessments, physician assessment forms (PAFs) and medical claims in accordance with CMS risk adjustments diagnosis coding guidelines
- Retrieve Medical Records From Different Facilities Onsite and also Piedmont Remotely
- Uses multiple EMR systems to access records following all HIPAA guidelines
- Collaborates with provider offices through phone calls and visits
- Schedule appointments and visits to physician offices in an orderly timely, efficient manner to meet all deadlines
- Will assist with regional phone calls and administrative projects as needed
- Remote
Customer Advocate Medical/Dental Departments
Blue Cross And Blue Shield
12.2017 - 01.2021
- Provide expertise or general claims support by reviewing, researching, investigating, negotiating, processing and adjusting claims
- Resolve medical claims by approving or denying documentations, calculating benefits due, initiates payments or composing denial letter
- Strive to have no backlog or un-posted revenue at the end of each month; set team expectations to achieve this goal
- Prove records of attention to detail and commitment to accuracy in work performed including the ability to enter data accurately in end -user computer applications (MS Office, electronic health/medical records and patient billing and other medical information systems
- (EPIC, Cerner, Citrix etc.)
- Examines and processes claims and/or non-medical appeals according to business/contract regulations, internal standards and examining guidelines
- Enters claims into the claim system after verification of correct coding of procedures and diagnosis codes
- Ensures claims are processing according to established quality and production standards
- Evaluates various types of requests and incoming correspondence to determine category of information and/or PHI requested, and HIPAA requirements departmental guideline
- Remote
Education
High School Diploma - undefined
G.W. Carver High School
Columbus, Georgia05.2014
Skills
- Attention to detail
- Fast Learner
- Medical Terminology
- Claims processing
- Call center experience
- Medical terminology
- Data entry proficiency
- EHR management
- Insurance billing
- Team leadership
- Medical coding
- Insurance company billing
- De-escalation techniques
- Database management
- Remote office availability
Languages
English
Timeline
Risk Adjustment Representative2
Humana Inc
01.2021 - Current
Customer Advocate Medical/Dental Departments
Blue Cross And Blue Shield
12.2017 - 01.2021
High School Diploma - undefined
G.W. Carver High School
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