Sharese Jones Email & Phone Number

United States

• Promoted to Medicare Analyst in the ‘Enrollment, Billing & Reconciliation - FIDE-SNP’ Department at Horizon BSBSNJ - Commercial Division, servicing DSNP (Dual Special Needs Program) members in the state of NJ• As a participant of Horizon’s new Buddy Program, I provide support to one newly hired employee to ensure a smooth transition from orientation, assist them with navigating the company’s culture and work environment, and participate in monthly touchpoint meetings with Program Leaders to share feedback• Investigate discrepancies listed under the members’ prescription drug plans from daily and monthly reports and email correspondences, and make necessary corrections and updates using FACETS, Trizetto, CMS.gov Enterprise Portal, Enrollment Administration Manager [EAM], and Electronic Medicaid Eligibility Verification System [EMEVS] systems• Conduct monthly and quarterly audits to ensure that member applications are processed correctly and timely• Contribute to triweekly Touchpoint Meetings to discuss eligibility discrepancies, technical issues to determine root cause, processing errors, and streamline of processes to formulate more efficient workflows• Download daily OEC files (electronic Member applications for three Horizon Commercial contracts) from the Health Plan Management System, and delegate them to the appropriate entities for processing

Hopewell, New Jersey, United States

• Promoted to MCC II in the Physical and Occupational Therapy Prior Authorization Department at Horizon NJ Health - Government Programs Division, servicing Medicaid and Medicare members in the state of NJ• Audit quality and performance reviews of service requests, implement on-boarding and training of all new Managed Care Coordinator staff, and streamline and develop process flows and procedural updates in the department• Initiate screening and prior authorization of up to 60 Home and Outpatient Physical and Occupational Therapy and Chiropractic precertification requests per day from physicians/members via incoming calls, correspondences, or electronic submission based on scripts and workflows, and under the oversight of clinical staff

United States

• Processed up to 60 Home and Outpatient Physical and Occupational Therapy pre-service requests per day for completeness of information, collection and transfer of non-clinical data, and acquisition of structured clinical data from physicians/patients• Conducted monthly quality audits of other Managed Care Coordinator staff• Coordinated training of new and current staff members within the department, and provided coaching to staff as necessary

United States

• Functioned as a MCC I in the Prior Authorization Department at Horizon Blue Cross Blue Shield - Commercial Division• Supported the Health Services and Utilization Management functions and acted as a liaison between Members, Physicians, Delegates, Operational Business members and Member Service Coordinators in a call center setting • Managed initial screening for up to 45 Inpatient and Outpatient pre-certification requests per day from physicians/members via incoming calls, faxes, or electronic submissions based on scripts and workflows, and under the oversight of clinical staff

Hamilton, Nj

• Promoted to Continuous Quality Improvement Specialist at NJ Family Care• Monitored and assessed individual/group performance against established standards/requirements and entered Quality Assurance review results into database for scorecard reporting, data analysis and trend identification, completing up to 70 audits per month• Provided feedback to leadership teams and addressed education/training needs with Project Director, Managers and Supervisors to include preparing summaries and launching presentations when appropriate

United States

• Received up to 40 inbound calls from members covered by NJ State Medicaid in a call center setting, and responded to inquiries regarding NJ Family Care Medicaid Program using standard scripts and procedures• Maintained a quality score of 1000 (Range 0-1000) for more than 12 consecutive months• Gathered information regarding eligibility and case status, researched/resolved inquiries and logged customer calls

Trenton, Nj

• Assessed more than 20 daily written correspondences and telephone calls from NJ state sentenced inmates and their families with concerns within the prison system (i.e. living conditions, abuse, property, parole, harassment, etc.)• Gathered and documented inmate contact information with their concerns into the Microsoft Access database, and redirected information to an Assistant Ombudsman for investigation• Accompanied Corrections Ombudsmen on occasional prison visits and inmate classification meetings

Master Of Public Administration - Mpa, Public Administration

Bachelor Of General Studies, General Studies

Education record

High School Diploma

Activities and Societies: National Honors Society Student Government Prince University Preparatory Program (PUPP) Choir