Alicia Elswick
Northern Michigan
Summary
Senior Healthcare Investigative Analyst with over 10 years of experience specializing in clinical operations, insurance coordination, and forensic auditing. Proven track record in workflow analysis, process improvement, and cross functional team leadership. Expert in EMR systems and medical billing logic currently seeking to leverage deep institutional knowledge to transition into an Epic Analyst or Senior SIU Analyst role.
Overview
2027
2027
years of professional experience
Work History
Claims & Clinical Systems Analyst
Aetna / CVS Health
Northern MI
- Leveraged multi-layered healthcare databases MHK, Medcompass, CLI to investigate and resolve high stakes provider grievances and complex claims discrepancies.
- Performed deep dive investigations into clinical coding, billing logic, and authorization errors, identifying the root cause of system inaccuracies and driving technical resolutions.
- Collaborated with cross functional teams to refine system configurations, reducing recurring errors in provider reimbursement and clinical authorizations.
Customer Service Representative
Aetna Better Health Medicaid
Southfield, MI
- Managed insurance coverage verification and complex benefit configuration inquiries for members and providers.
- Identified and escalated systemic software and workflow issues to leadership to improve service standard goals and department throughput.
Verification Representative
National Health Plans & Benefit Agency
Fraser, MI
- Reviewed insurance policy applications for technical errors to minimize organizational risk and ensure payer accuracy.
Front Desk Receptionist
Concentra
Sterling Heights, MI
- Coordinated patient scheduling and data entry within the EMR, ensuring 100% adherence to HIPAA privacy laws and data security protocols.
Patient Registration Clerk
McLaren Macomb Hospital
Mount Clemens, MI
- Facilitated accurate patient placement and insurance verification within the hospital registration system to ensure clean claim submission.
Senior SIU Investigative Analyst
Aetna / CVS Health
01.2025 - Current
- Conduct comprehensive audits of Medicare Part D grievance cases to ensure 100% alignment with CMS regulatory frameworks and internal risk mitigation standards.
- Analyze complex performance datasets to identify systemic trends deliver executive level briefings and actionable findings to leadership to enhance member experience and operational efficiency.
- Engineered research methodologies to verify First Call Resolution FCR metrics, identifying documentation gaps and implementing process improvements to ensure data integrity.
- Serve as a Subject Matter Expert SME on CMS regulations, mitigating organizational liability through rigorous quality assurance and detailed investigative reporting.
Education
High School Diploma - undefined
Edison High School
Plainfield, NJCertified Office Assistant Coursework - undefined
01.2008
Skills
- Systems: Epic EMR Ambulatory Tapestry MHK, Medcompass, CLI, EMR Data Entry & Workflow
- Analytic Tools: Advanced Excel VLOOKUPs/Pivot Tables, Root Cause Analysis, Data Visualization
- Compliance CMS Regulations Medicare Part D, ERISA Guidelines, HIPAA, Clinical Coding Accuracy
- Expertise Forensic Auditing, Fraud/Waste/Abuse FWA Identification, Process Optimization
EARLY CAREER HISTORY
- Kindred Hospital Unit Clerk Detroit, MI
- Woman to Woman Medical Center Benefit Claim Specialist Freehold Township, NJ
Timeline
Senior SIU Investigative Analyst
Aetna / CVS Health
01.2025 - Current
Customer Service Representative
Aetna Better Health Medicaid
Verification Representative
National Health Plans & Benefit Agency
Front Desk Receptionist
Concentra
Patient Registration Clerk
McLaren Macomb Hospital
High School Diploma - undefined
Edison High School
Certified Office Assistant Coursework - undefined
Claims & Clinical Systems Analyst
Aetna / CVS Health