Kathy Shields Email & Phone Number

Atlanta, Ga

Served as business analytics liaison for clinical quality complex core teams, nursing, health administration, and related clinical teams. Responsible for business system functions, resources person and teacher to clinical health population program teams. Experience in clinical support, claims informatics, clinical application training, workflows, medical terminology, and ad-hoc reporting. Providing oversight to assure accurate and complete analysis of clinical data and presentation of data analysis. Research, monitor, and implementation of process improvement that target populations across multiple regions.

Atlanta, Ga

Utilization management operation outreach providing support for client engagement.Identify barriers through obc assessment tool related to quality program that meet best practices. Provided support and guidance on system training, clinical management , quality improvement, and clinical quality operations. Provided onboard system training to case managers, social workers and other medical management teams. Researched and interpreted conceptual modules workflow and process diagrams to assign census and NOMNC clinical cases to case managers and social workers. Managed inpatient, outpatient, specialty cases such as anesthesia, physical therapy, cancer, chronic care ERISA concurrent review and discharge planning cases during backlog.

Greater Atlanta Area

Managed Insurance verification, pre-certification, billing, computer skills and effective communication for advanced cancer treatment for 46 physicians provide care in 27 Northside Hospital Cancer Institute locations in Metro Atlanta, North and Central Georgia. Predetermination, and redetermination approvals for outpatient, and inpatient cancer drug treatment. Assist office manager with daily crystal reporting, audits and employee training. Coordinated oncology radiology services, PET/CT, Cancer Diagnoses and High cost Drugs plan contractual pricing overpayments. Request referral from primary care providers, and prior authorization from members plan of service.

Norcross, Ga

Maintained departmental policies and procedures, objectives, patient, and customer service policies to effectively resolve contractual claims issues, and improve goals for managed facilities that include more than 170 hospitals and 119 freestanding surgery centers. Utilized technical MEDITECH, Parallon and EPIC skills that improved organizational business processes and patient care through strategy and analysis solutions. Working knowledge of managed care, application, hospital claims billing, contracts, and accounts payable, benefits costs tracking and CMS regulations.

Greater Atlanta Area

Problem solve, research and analyzes claims issues. Claims adjudication of professional, national, speciality and inpatient claims for members and providers. Provided professional representation on multiple claims benefit configuration level. Helped managers, specialists, external vendors and co-workers on system and claims issues. Utilized network pricing application for CPT coding and fee scheduling in COB files to meet policy and procedure. Skills database system and related software word processing and spreadsheet.

Bachelor’S Degree, Business Healthcare Management

Activities and Societies: Dean's List Fall 2015-March 2018health informatics, reporting & data analysis, research & professional.

Associate’S Degree, Business Management

Activities and Societies: Dean's List Spring 2013-2014 Dean's List Fall 2014- 2015 Spire's Honors GraduateAssociate of Arts program.