Shayana Edwards
San Diego
Summary
Administrative and analytical professional with expertise in insurance adjudication and operations management. Focused on data integrity and process improvements, consistently optimizing workflows to enhance revenue cycles and ensure compliance. Committed to delivering high-quality service through effective problem-solving and attention to detail.
Overview
13
13
years of professional experience
Work History
Inside Sales Representative
Sequel Med Tech
San Diego, California
03.2025 - 06.2026
- Increasing sales and providing customer support and service options/recommendations
- Call requirement of 50 calls per day
- Listen and assess the needs of each customer, and quickly provide appropriate solutions
- Follow-up on all pending and recommended work with customers and their technicians
- Build sustainable relationships of trust through open and interactive communication
AUTHORIZATION SPECIALIST
Fortuna BMC
San Diego, CALIFORNIA
09.2024 - 01.2025
- Insurance Verification: Confirming patient eligibility and active coverage before services are rendered.
- Prior Authorization Processing: Submitting clinical documentation (doctor's notes, test results) to insurance companies to obtain approval for surgeries, medications, or specialized tests.
- Medical Necessity Review: Ensuring the requested service meets the specific "criteria for care" set by the insurance payer.
- Denial Management: Reviewing denied requests, identifying missing information, and coordinating with the clinical team to file appeals.
- Liaison Work: Communicating between patients, physicians, and insurance adjusters to resolve administrative bottlenecks.
DATA ANALYST
Tourine industries
San Diego, CALIFORNIA
01.2021 - 08.2024
- Data Collection & Cleaning: Pulling data from databases (SQL, Excel) and "cleaning" it to remove errors, duplicates, or missing values.
- Statistical Analysis: Using mathematical models to find patterns, correlations, or trends within large datasets.
- Visualization: Creating charts, graphs, and dashboards (using tools like Tableau or PowerBI) to make data easy for others to understand.
- Reporting: Presenting findings to management to answer specific questions, such as "Why are sales down?" or "How can we be more efficient?"
- Monitoring Trends: Tracking Key Performance Indicators (KPIs) to alert the team when performance dips below a certain threshold.
AUTHORIZATION SPECIALIST
Kaiser Permanente
San Diego, CALIFORNIA
05.2020 - 01.2021
- Insurance Verification: Confirming patient eligibility and active coverage before services are rendered.
- Prior Authorization Processing: Submitting clinical documentation (doctor's notes, test results) to insurance companies to obtain approval for surgeries, medications, or specialized tests.
- Medical Necessity Review: Ensuring the requested service meets the specific "criteria for care" set by the insurance payer.
- Denial Management: Reviewing denied requests, identifying missing information, and coordinating with the clinical team to file appeals.
- Liaison Work: Communicating between patients, physicians, and insurance adjusters to resolve administrative bottlenecks.
OFFICE MANAGER
Tierra town dental center
Mira Mesa, CALIFORNIA
09.2018 - 02.2020
- Revenue Cycle Management: Overseeing billing, insurance claims, and patient co-pays to ensure the office remains profitable.
- Schedule Optimization: Managing the doctor's and hygienists' calendars to maximize patient flow and minimize "no-show" gaps.
- Patient Coordination: Handling patient intake, treatment plan presentations, and financing discussions.
- Compliance & HIPAA: Ensuring the office follows all healthcare privacy laws and safety regulations (OSHA).
- Team Leadership: Managing front-office staff, ordering supplies, and acting as the point of contact for external vendors.
DATA ANALYST INTERN
Alta motors
San Diego, CALIFORNIA
06.2017 - 08.2018
- Assisted in creating dashboards to visualize key performance indicators for management.
- Supported the development of predictive models using historical data analysis techniques.
- Participated in team meetings to discuss project goals and share insights on findings.
- Performed exploratory data analysis on large datasets to identify trends and outliers.
INSURANCE CLAIMS SPECIALIST
Whips motorcycle insurance
San Diego, CALIFORNIA
12.2013 - 07.2016
- Investigation: Reviewing police reports, witness statements, and photos to determine liability (who is at fault).
- Policy Interpretation: Reading the "fine print" of an insurance contract to see if a specific event is covered or excluded.
- Damage Assessment: Evaluating repair estimates or medical bills to ensure the costs are fair, reasonable, and related to the claim.
- Negotiation: Settling with third parties, attorneys, or repair shops to reach a final dollar amount for the claim.
- Adjudication: Issuing payments to policyholders or vendors and documenting the legal justification for the payout.
Education
ASSOCIATE IN SCIENCE (A.S.) - APPLIED PSYCHOLOGY
Grossmont College
San Diego, CA06-2026
Associate of Arts - Behavioral Sciences
Grossmont College
San Diego06-2026
Skills
- Medical terminology proficiency
- Insurance verification
- Medical coding
- Medical Billing
- Claims management
- Microsoft office
- CRM software expertise
- HIPAA compliance
- Excel functions
- Sales
References
References available upon request
Education
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Timeline
Inside Sales Representative
Sequel Med Tech
03.2025 - 06.2026
AUTHORIZATION SPECIALIST
Fortuna BMC
09.2024 - 01.2025
DATA ANALYST
Tourine industries
01.2021 - 08.2024
AUTHORIZATION SPECIALIST
Kaiser Permanente
05.2020 - 01.2021
OFFICE MANAGER
Tierra town dental center
09.2018 - 02.2020
DATA ANALYST INTERN
Alta motors
06.2017 - 08.2018
INSURANCE CLAIMS SPECIALIST
Whips motorcycle insurance
12.2013 - 07.2016
Associate of Arts - Behavioral Sciences
Grossmont College
ASSOCIATE IN SCIENCE (A.S.) - APPLIED PSYCHOLOGY
Grossmont College