Summary
Overview
Work History
Education
Skills
Certification
Job Skills
Timeline
Generic

SHAMEKIA DANIELS

Raleigh

Summary

Accomplished operations leader with expertise in authorization management and person-centered planning at Carolina Community Support. Demonstrated excellence in crisis intervention and effective communication, enhancing operational efficiency by 20%. Proven track record in staff management and compliance monitoring, ensuring quality assurance and fostering a positive, collaborative work environment.

Overview

13
13
years of professional experience
1
1
Certification

Work History

Assistant Director of Operations

Carolina Community Support
08.2024 - Current
  • Oversee Enhanced Services CST, IIH, PSS
  • Submit Authorizations for enhanced programs through PHP’s
  • Review PCP’s
  • Assign staff to work with consumers who are ready for services

PSS Qualified Professional

Complete WellCare
02.2023 - Current
  • Document client progress to maintain a permanent record of client activity according to established methods and procedures
  • Ensures immediate changes are made in treatment plans.
  • Advocate for the client's rights and preferences.
  • Create initial PCPs
  • Update PCPs

Utilization Director/Peer Support Supervisor/ Qualified Professional

Upward Change Health Services
02.2022 - Current
  • Submit authorization to various Medicaid Insurances including WellCare, Carolina Complete, Healthy Blue, United Healthcare and AmeriHealth
  • Submit authorization to various Private Insurance agencies such as Blue Cross Blue Shield and Aetna
  • Obtain authorization for various clients on behalf of patients in all levels of care
  • Utilize various software's such as EMR systems, KIPU, Salesforce, SharePoint, Microsoft Word, and Excel, and other related systems
  • Communicate via phone in a professional manner with call representatives
  • Communicate in a professional manner with our clients and personnel in-person, via email, or via phone calls
  • Multitask between phone calls and online resources
  • Make accurate, clinically appropriate, and consistent approval authorization determinations, including collecting appropriate clinical information, applying appropriate medical criteria, consulting with Medical Director, and communicating authorization determinations to providers, members or patients in accordance with policy and procedure and within timeliness requirements
  • Conduct PCP update, ensure accurate and valid documentation, complete discharges, provide peer support services
  • Receive, review, process, file and/or submit a variety of documents and reports and electronic files on client's including time studies, performance ratings, time sheets, data sheets, production sheets, professional contact sheets, accident reports, client satisfaction surveys, etc
  • Works closely with other clinical/professional staff to maintain communication and provide feedback, standard procedures, expedite employment plan implementation.

Peer Support Qualified Professional

Aspire Supportive & Counseling Service, LLC
Raleigh
07.2013 - 05.2022
  • Reviewed and submitted payroll for the North Carolina Certified Peer Support Specialist (CPSS)
  • Compares payroll to billing to ensure staff are accurately recording their time based on the services provided
  • Generated and maintained weekly reports regarding new and outstanding authorizations
  • Documented efforts to identify and address authorization, unpaid claims, and payment problems
  • Developed and updated the Person-Centered Plan (PCP) with consumer, crisis plans and Service Authorization Request (SAR) for providing appropriate services
  • Conducted internal audits of services provided to identify any problem areas and make needed corrections and changes in procedure
  • Oriented new staff, training team consultants and volunteers and oversee the hiring process for the program
  • Overseed data collection, analysis, and reporting related to the CPSS program; ensure that all program requirements are being met including written reports
  • Coordinated and develop relationships with community resources to educate the community about the CPSS role and Program and remain current regarding CPSS practice and workforce development
  • Provided observation of consumer's behaviors and functioning and report any changes to the clinical team lead
  • Responsible for accurate documentation of services and maintaining consumer medical records as required by agency policy, government regulations, and applicable local, state, and federal codes
  • Attended in-service training and collaboration with Alliance Behavioral Healthcare for Peer Support Services

Program’s Director Qualified Professional

1st Choice Health Services
Greensboro
01.2017 - 12.2017
  • Provided ongoing communication/consultation with other professions and consumer's families and natural support systems
  • Facilitated routine utilization reviews to determine if criteria for a consumer's authorization were met
  • Facilitated the initial and on-going development, implementation and monitoring of services as identified in the Person-Centered Plan
  • Worked in a team approach to facilitate meetings necessary to ensure coordination of service delivery and implementation of person-centered plans
  • Provided scheduled therapeutic interventions to facilitate skill building, community living skills, psychoeducation to prevent and/or recover from substance abuse, socialization skills, adaptation skills, development of leisure time interests/activities, symptom management skills, wellness education, psychoeducation, work readiness skills and behavior/anger management
  • Assisted consumers in accessing services and other resources via referrals, linking, coordinating, etc
  • Provided on-call Crisis/First-Responder interventions to ensure coverage is available to consumers
  • Monitored the timely and accurate completion of progress notes for their assigned Community Support Team service unit and ensure compliance with Triumph policy and Medicaid standards

Program’s Director Qualified Professional

Life Foundations Wellness and Supportive Counseling
01.2014 - 05.2015
  • Developed Person Centered Plans and complete SARs in accordance with NC Clinical Coverage Policy 8C
  • Evaluated and verified information to determine compliance and currency with all state and local management entity regulatory standards
  • Compiled, coded, categorized, calculated, audited and organized system management processes to track deadlines pertinent to initial and concurrent authorization approvals
  • Input all new and concurrent authorization requests for services within a timely manner and prior to expiration dates; ensuring all appropriate and required supporting documentation is in place
  • Assisted with the execution of quarterly audits on all charts; both active and discharged
  • Prepared and submit weekly status reports of approved and/or denied treatment plans
  • Completed discharge plans and daily full service notes in accordance with NC DMA Policy Number 8A

Intensive in Home QP

Faithworks Community Support Services
Raleigh
09.2012 - 01.2014
  • Managed monthly budget for organizing and leading planned recreational activities
  • Organized and facilitated therapeutic services to mentally challenged, delinquent, abused and disabled children and teens in daily life skill sessions
  • Completed daily, weekly and monthly time sensitive documentations
  • Maintained open communications with parents, social worker, case managers, therapist and teachers on children and teens behaviors and improvements
  • Proficient with dispensing and logging daily medications
  • Instructed staff on maintaining and implementing policies and procedures of the group home
  • Was certified in first aid, CPR, and physical restraints on aggressive clients using approved techniques and procedures

Education

Master of Science - Human Services

Kaplan University
Online

Bachelor of Science - Criminal Justice

Mount Olive College

Skills

  • Calm Under Pressure
  • Friendly, Positive Attitude
  • Excellent Communication
  • Decision-Making
  • Microsoft Word
  • Microsoft Excel
  • Microsoft PowerPoint
  • Integrity
  • Share-Notes
  • Word Processing
  • Database Management
  • Knowledge of Labor Law
  • NC Tracks
  • Alpha Provider Portal
  • Authorization management
  • Person-centered planning
  • EMR systems
  • Documentation accuracy
  • Compliance monitoring
  • Utilization review
  • Staff training
  • Medicaid regulations
  • Treatment plan development
  • Crisis intervention
  • Effective communication
  • Problem solving
  • Advocacy skills
  • Attention to detail
  • Operational efficiency
  • Process improvements
  • Conflict resolution
  • Quality assurance
  • Teamwork
  • Staff management
  • Customer service

Certification

Certified Peer Support Specialist

Job Skills

  • Microsoft Word
  • Microsoft Excel
  • Microsoft PowerPoint
  • Integrity
  • Share-Notes
  • Word Processing
  • Database Management
  • Knowledge of Labor Law
  • NC Tracks
  • Alpha Provider Portal

Timeline

Assistant Director of Operations

Carolina Community Support
08.2024 - Current

PSS Qualified Professional

Complete WellCare
02.2023 - Current

Utilization Director/Peer Support Supervisor/ Qualified Professional

Upward Change Health Services
02.2022 - Current

Program’s Director Qualified Professional

1st Choice Health Services
01.2017 - 12.2017

Program’s Director Qualified Professional

Life Foundations Wellness and Supportive Counseling
01.2014 - 05.2015

Peer Support Qualified Professional

Aspire Supportive & Counseling Service, LLC
07.2013 - 05.2022

Intensive in Home QP

Faithworks Community Support Services
09.2012 - 01.2014

Master of Science - Human Services

Kaplan University

Bachelor of Science - Criminal Justice

Mount Olive College

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SHAMEKIA DANIELS