SHERRITA KELLEY
SHERWOOD
Summary
Detail-oriented and results -driven Claims Examiner with extensive experience in claims processing, auditing, and prior authorization management. Skilled in reviewing, analyzing, and resolving complex medical and insurance claims while ensuring regulatory compliance. Proficient in HRP, Aerial, Javelina, Salesforce, Availity, CMS, Ahin, Amysis, AWS systems, with a strong focus on accuracy, workflow efficiency, and effective communication with providers and teams.
Overview
5
5
years of professional experience
Work History
Claims Processor
SGS International
05.2025 - 01.2026
- Reviews processed claims and inquiries to determine corrective action which can include adjusting claims
- Reviews claims to ensure the correct provider or practice is selected
- Takes the corrective action steps using enrollment, benefit, and historical claim processing information
- Determine if claim information is complete and correct
- Resolve claim edits, review history records, and determine benefit eligibility for service
- Meets all production and quality standards
- Attends all required training classes
- Elevates issues to next level of supervision, as appropriate
- Maintains accurate records, including timekeeping records
- Collaborate with cross-functional teams to perform TPA audits, identify discrepancies, and implement corrective actions to maintain operational accuracy and compliance.
- Manage a high volume of claims, ensuring complete documentation, accurate determinations, and adjudication within authority limits while meeting quality and productivity.
- Process and adjudicate complex healthcare claims, including reviewing authorizations and prior approvals, working all triggers in HRP, and routing claims to the appropriate workbaskets as necessary.
- Gathered facts before making final determination on claims with accurate decision-making skills.
- Gained experience across appropriate codes, health insurance principles, medical terminologies, subrogation, reinsurance, compensation, third party liability and coordination of benefits claims.
Claims/Prior Authorizations Specialist
Medtronic
01.2024 - 01.2025
- This was a temporary position
- Assisted with medical necessity documentation to expedite approvals and confirm appropriate follow-up.
- Processed referrals and submitted medical records to insurance carriers to expedite prior authorization processes.
- Managed correspondence with insurance companies, physicians and patients as required.
- Processed referrals and submitted clinical supporting documentation to insurance carriers to expedite prior authorization processes.
- Assisted on processes claims with approval authorizations.
Claims Auditor
Wipro Technologies
06.2021 - 06.2023
- Completes reporting of audits finalized with decision methodology for procedural and monetary errors, which are used for quality reporting and trending analysis utilizing QA tools.
- Perform auditing of claims, ensuring processing, payment, and financial accuracy by verifying all aspects of the claim have been handled correctly and according to both standard process and the client's summary plan description.
- Process and adjudicate complex healthcare claims, including reviewing authorizations and prior approvals, working all triggers in HRP, and routing claims to the appropriate workbaskets as necessary.
- Support staff and collaborate on special projects such process documentation, training support, quality audits, and surge initiatives, contributing to consistent claim outcomes and operational efficiency.
Education
ASSOCIATE OF SCIENCE -
Pulaski Technical College
North Little Rock, ARSkills
- Processing denials
- Processing appeals
- Claims processing
- Benefit eligibility
- Auditing techniques
- Medical terminology
- Compliance standards
- Quality assurance
- Healthcare regulations
- Risk management
- Attention to detail
- Insurance regulations
- Claims processing software
- Claims
- Claims review
- Insurance coverage verification
- Claims adjustment
- Analytical thinking
- Insurance plan verification
- Denied claims identification
- Medicaid
- Customer service
- Authorization management
- Prior authorization process
- Workflow management
- ICD-10 coding
- Pharmacy benefit management
Timeline
Claims Processor
SGS International
05.2025 - 01.2026
Claims/Prior Authorizations Specialist
Medtronic
01.2024 - 01.2025
Claims Auditor
Wipro Technologies
06.2021 - 06.2023
ASSOCIATE OF SCIENCE -
Pulaski Technical College