KIM SHEGOG
Drexel Hill,PA
Summary
Lead Clinical Appeals Coordinator with extensive experience in medical necessity review, regulatory compliance, and denial management. Strong background in coaching teams, optimizing workflows, and ensuring high-quality appeal determinations. Known for critical thinking, policy interpretation, and the ability to navigate complex insurance regulations while supporting organizational goals.
Overview
20
20
years of professional experience
1
1
Certification
Work History
Lead Clinical Appeals Coordinator
Independence Blue Cross
Philadelphia, PA
01.2024 - Current
- - Monitor daily inventory and distribute workloads to ensure timely and compliant appeal processing
- - Coach and mentor Appeals Coordinators, providing performance feedback and supporting skill development
- - Serve as subject matter expert for appeal processes, regulatory requirements, and internal workflows
- - Deliver hands-on training and onboarding for new associates
- - Audit appeal files for quality assurance and present findings and trends to leadership
- - Identify gaps in denial management processes and implement corrective actions
Clinical Appeals Coordinator
Independence Blue Cross
Philadelphia, PA
01.2015 - 01.2024
- - Reviewed and analyzed appeal requests for medical necessity and regulatory compliance
- - Organized and prepared case files for external review per state and federal guidelines
- - Gathered and evaluated clinical documentation to support accurate determinations
- - Conducted thorough case screenings to ensure all required documents were included
- - Prepared compliant response letters for members and providers
- - Collaborated with medical directors to clarify clinical rationale and ensure consistency
Private Duty Nurse
Self-employeed
Drexel Hill, PA
01.2014 - 01.2015
- - Delivered individualized nursing care in home settings
- - Monitored patient conditions, administered medications, and educated families
- - Ensured safe, compassionate, patient-centered care
Rehabilitation Care Coordinator
Delaware County Memorial Hospital
Drexel Hill, PA
01.2010 - 01.2014
- - Coordinated rehabilitation services and discharge planning for a 24 bed unit
- - Collaborated with interdisciplinary teams to support continuity of care
- - Educated patients and families on treatment plans and recovery expectations
Telemetry Staff Nurse
Delaware County Memorial Hospital
Drexel Hill, PA
01.2006 - 01.2010
- - Provided direct patient care on a telemetry unit
- - Monitored cardiac rhythms, performed assessments, and administered medications
- - Responded to changes in patient condition and collaborated with physicians
Education
Master of Science - Healthcare Administration
Rosemont College
Bryn Mawr, PA05.2022
Bachelor of Science - Nursing (BSN)
Immaculata University
Immaculata, PA05.2010
Associate Degree - Nursing (ADN)
Delaware County Community College
Media, PA05.2006
Skills
- - Clinical Appeals & Denial Management
- - Medical Necessity Review
- - Insurance Regulations & Compliance
- - Policy Interpretation
- - Quality Assurance Auditing
- - Workflow Optimization
- - Training, Coaching & Mentorship
- - Microsoft Office (Excel, Word, PowerPoint)
- - Dispute Resolution
- - Critical Thinking & Problem Solving
- - Multitasking & Prioritization
Certification
Registered Nurse (RN) — State of Pennsylvania
Timeline
Lead Clinical Appeals Coordinator
Independence Blue Cross
01.2024 - Current
Clinical Appeals Coordinator
Independence Blue Cross
01.2015 - 01.2024
Private Duty Nurse
Self-employeed
01.2014 - 01.2015
Rehabilitation Care Coordinator
Delaware County Memorial Hospital
01.2010 - 01.2014
Telemetry Staff Nurse
Delaware County Memorial Hospital
01.2006 - 01.2010
Master of Science - Healthcare Administration
Rosemont College
Bachelor of Science - Nursing (BSN)
Immaculata University
Associate Degree - Nursing (ADN)
Delaware County Community College