Shelondia Winston
Pembroke Township
Summary
Detail-oriented and results-driven professional with over 15 years of progressive experience in claims administration, benefit auditing, appeals resolution, and financial recovery within high-volume healthcare environments. Demonstrated success in identifying discrepancies, executing root cause analysis, and implementing process improvements that enhance claim accuracy and compliance. Adept at collaborating with business operations, IT, and third-party vendors to resolve complex claim issues. Recognized for delivering exceptional attention to detail, driving operational efficiency, and supporting enterprise-level initiatives. Proven ability to interpret policy provisions, audit benefit setups, and manage escalated cases with precision and professionalism.
Overview
15
15
years of professional experience
Work History
Business Analysis Lead Analyst
The Cigna Group | Proclaim
01.2020 - 01.2025
- Delivered comprehensive auditing feedback by applying SOPs, checklists, and job aids to ensure accuracy and compliance with Cigna’s operational guidelines. Contributed to team alignment and knowledge sharing by engaging in daily huddles, team meetings, and training sessions. Developed project documentation including business cases, workflows, and impact assessments to support decision-making.
- Delivered first-level technical support and troubleshooting for Business Operations applications, ensuring timely issue resolution.
- Acted as a liaison between Business Operations and IT teams while advocating for business needs and driving issue resolution.
- Investigated and resolved complex claim-related issues through collaboration with team coaches, clients, and third-party vendors.
- Demonstrated strong attention to detail by performing root cause analysis, updating standard operating procedures (SOPs), and creating clear, effective communications to support process improvements and operational consistency.
- Delivered first-level ticket triage and resolution, including managing application crises, coordinating real-time communication, and generating incident reports to support timely issue closure.
Quality Review & Audit Lead Representative / Contract Sr Associate
The Cigna Group | Proclaim
01.2015 - 01.2020
- Performed end-to-end quality reviews and audits on claims processing aimed at ensuring compliance with internal policies, contractual obligations, and regulatory standards. Led internal business communications for high-impact and critical issues with keen emphasis on ensuring timely updates and alignment between IT and business units from issue identification through resolution.
- Accelerated resolution of business-critical incidents and minimized operational disruptions through cross-functional coordination.
- Resolved complex customer inquiries using independent judgment, ensuring high levels of client satisfaction and service quality.
- Performed detailed audits to ensure accurate benefit setup and compliance with organizational guidelines and regulatory standards, while identifying and correcting discrepancies to maintain data integrity.
- Provided project support across multiple initiatives, including Problem Referral, Intake Analysis, and Innovation Projects, while contributing to process improvements and business efficiency.
Financial Recovery Specialist
The Cigna Group | Proclaim
01.2012 - 01.2015
- Monitored and reported emerging trends or critical client concerns to management for timely escalation and resolution. Developed and delivered external communications, including client letters and talking points, to support consistent and professional messaging. Managed provider and client correspondence related to financial recoveries, including drafting formal communications and resolving disputes.
- Reviewed claims associated with received refunds to verify payment accuracy; recovered overpayments or initiated reissuance of payments when refunds were received in error, with keen focus on ensuring financial accuracy and compliance.
- Conducted thorough cause analyses on complex claim issues, driving resolution and process improvement through to completion.
- Trained and onboarded new team members while ensuring knowledge transfer and team readiness.
Appeals Processor Sr Associate
The Cigna Group | Proclaim
01.2010 - 01.2012
- Collaborated with Small, Regional, and National accounts to analyze the impact of claim payments on provider and customer satisfaction, with strong focus on driving improvements in service delivery and relationship management. Reviewed and analyzed appeal requests from customers and healthcare professionals while ensuring compliance with organizational and regulatory guidelines.
- Effectively managed high-priority escalated issues via workflow tools aimed at ensuring timely and accurate resolution.
- Conducted investigations of disputed claims against Standard Operating Claim Payment Procedures to determine outcomes.
- Processed adjustments for approved appeals and issued formal communications for upheld decisions.
Education
Momence High School
Momence, IL05.1999
Skills
- Claims processing and oversight
- Collaborative teamwork
- Attention to detail
- Effective communication
- Appeals and adjustments resolution
- Benefit auditing and configuration
- Eligibility review and authorization
- Project management expertise
- HIPAA compliance
- Claims overpayment recovery
- Vendor coordination
- Root cause analysis
Websites
Additional Experience
- Correspondence Processor Sr Associate
- Claims Processor Sr Associate
- The Cigna Group | Proclaim
- Accounts Payable Specialist
- Baker & Taylor
Timeline
Business Analysis Lead Analyst
The Cigna Group | Proclaim
01.2020 - 01.2025
Quality Review & Audit Lead Representative / Contract Sr Associate
The Cigna Group | Proclaim
01.2015 - 01.2020
Financial Recovery Specialist
The Cigna Group | Proclaim
01.2012 - 01.2015
Appeals Processor Sr Associate
The Cigna Group | Proclaim
01.2010 - 01.2012
Momence High School
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