1. Tamishia Clayborn
Tamishia Clayborn
7870 Locher Way #24
Citrus Heights, CA 95610
Cell: 916-470-2469
tclayborn77@yahoo.com or shanilove2001@yahoo.com
BUSINESS MANAGEMENT EXECUTIVE
Successful results driven senior insurance operations executive offering over 13 years of
experience in the insurance industry, operational growth, maintaining business structure,
maximizing business opportunities, and ensuring compliance with regulatory insurance
requirements. Genuine talent in building trust relationships in written and verbal communication
across all age groups and levels of an organization. Excellent leadership qualifications, customer
relationship management/follow through, and employee training/supervision. Sincere with a
client-focused approach that generates trust and allegiance. Skilled in MS Office, internet, and
other propriety programs
- Operations & General Management - Team Building & Leadership
- Marketing & Business Development - Professional & Personable Attitude
- Customer Care & Service - Rapport Building
- Strategic Planning & Operational Budgeting - Skilled Multi-tasking Ability
- General Operations & Productivity Improvement - Insurance Claims Ops. Expertise
EDUCATION
Undergraduate Degree: B.A. English/African & African-American Studies, UC, Davis, June 2000
Graduate Degree: M.B.A. University of Phoenix, September, 2008
PROFESSIONAL EXPERIENCE
BENEFIT INTEGRATION MANAGER 2012-Present
American Health Care Rocklin, CA
Managed consistent written and verbal communication between clients, members, and corporate associates
regarding implanting the pharmacy plan benefits purchased by the client. Managed the implementation
process from the initiation of the agreement to the launch of the benefit/product purchased by the client.
Maintain detailed records and developed client communication throughout the implementation process.
Maintained reporting and records for daily accounts payable and accounts receivable transactions between
the client and contracted pharmacies. Lead cost reduction and process improvement projects resulting in
improvement in department operations.
-Analytical and payment accuracy review of client/member files, forms, pharmacy benefit claims
-Pharmacy benefit coding/claim form knowledge, ICD-9/ HCPC/CPT coding, UB92/UB04/HCFA forms
SR. CLAIMS DEVELOPMENT SPECIALIST 2005-2012
Health Net, Inc. Rancho Cordova, CA
Maintained daily accounts receivable and accounts payable review of disputed medical claims. Managed
consistent written and verbal communication between members, providers, and corporate associates
regarding case file review and final determination of medical benefits available through the schedule of
benefit/health plan. Lead cost reduction and process improvement projects resulting in improvement in
department operations.
-Analytical and payment accuracy review of medical files, forms, claims
-Medical coding/claim form knowledge, ICD-9 coding, HCPC/CPT coding, UB92/UB04/HCFA forms
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2. Tamishia Clayborn
-Product knowledge of PPO, HMO, IFP, FLEXNET, FIRST HEALTH, HOME HEALTH, CSP,
HEMO/CHEMO, SPECIALTY PRODUCTS
M/O SR. CLAIM EXAMINER (Temp.) 2004-2005
State Compensation Insurance Fund (SCIF), Sacramento, CA
Managed daily overview of medical insurance claim submissions of workers compensation cases through
review of medical necessity of services rendered. Determined financial responsibility and
accounts receivable/payable of services approved. Manual data processing and accuracy review of medical
claims.
-Analytical and payment accuracy review of medical files, forms, claims
-Medical data accuracy confirmation of ICD-9 coding, HCPC/CPT coding, UB92/UB04/HCFA forms
AOE/COE FIELD WORKERS COMP. INVESTIGATOR 2003
MJM Investigations Inc., Sacramento, CA (home office)
Managed private field workers compensation claims investigation focused on direct communication with
claimants and insured clients. Maintained communication related to case developments and discoveries
determined through the investigation process. Lead stake-out/sub-rosa on site investigation of claimants
and recorded video documentation of daily activity.
-Determined medical necessity of injuries through face to face and telephone recorded statements
-Wrote detailed reports of investigation overview/ field video documentation
-Managed high volume case load and consistency (Case volume included traveling Northern.CA region)
SR. PROPERTY & CASUALTY CLAIM ADJUSTER 2001-2002
USAA Insurance, Sacramento, CA
Managed day to day customer relationships specific to property and casualty losses and claim submission
review. Performed extensive explanation of coverage of policy allowance/limitation. Immediate extensive
response to policy inquiry and financial responsibility. Maintained case review and completion of property
loss assessments. Lead team goal and accountability score for two months.
-Managed auto and property claim loss assessment with a case load of 250 or more
-Determined financial responsibility and percentage of liability based on recorded statement
PROPERTY & CASUALTY CLAIM ADJUSTER 2000-2001
Prudential Insurance, Roseville CA
Managed day to day customer relationships specific to property and casualty losses and claim submission
review. Performed extensive explanation of coverage of policy allowance/limitation. Immediate extensive
response to policy inquiry and financial responsibility. Maintained case review and completion of property
loss assessments. Lead team goal and accountability score for two months.
-Managed auto and property claim loss assessment with a case load of 250 or more
-Determined financial responsibility and percentage of liability based on recorded statement
COMMUNICATIONS SPECIALIST/OFFICE ASSISTANT 1997-2000
Prudential Insurance, Davis CA
Managed daily customer relationship development and establishment through direct contact to warm/cold
leads. Lead performance expectations through increasing client base by over 80% of the original client
volume. Maintained general office relations and trained staff in customer service and new customer
relationship development techniques.
-Maintained customer service relationships and response to product inquiry/review
-Established development of new client relationships through customer satisfaction analysis
-Maintained accurate records of new clientele interest and sales ratios per appointment
HONORS & INTERESTS
McNair Scholar, MURALS Scholar, Urban League YP Exec. Secretary 2006-2007
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