ALICIA ELSWICK
Curran,MI
Summary
Highly analytical Senior Healthcare Investigative Analyst and Project Leader with over a decade of hands on experience in clinical operations, claims appeals adjudication, and complex workflow analysis. Proven expertise in identifying systemic operational issues, performing comprehensive root cause analysis, and driving cross functional remediation strategies. Skilled at managing end to end project execution, facilitating stakeholder collaboration, and maintaining rigorous tracking metrics. Exceptional communicator adept at translating raw data into actionable monthly and ad hoc reports to empower executive decision making.
Overview
18
18
years of professional experience
Work History
Senior SIU Coordinator
Aetna / CVS Health
Remote
12.2025 - Current
- Root Cause Analysis Partner with leadership teams to define operational requirements for identifying the root causes of systemic processing issues, shifting the department from reactive tracking to proactive resolution.
- Project Execution Manage and execute cross functional initiatives aimed at systemic issue remediation, ensuring all milestones deliver within defined scope, timeline, and budget.
- Reporting & Visibility: Formulate and deliver comprehensive monthly and ad-hoc status reports detailing ongoing and resolved issues to provide senior leadership with clear visibility for strategic planning.
- Team Guidance: Administer leadership and guidance to decentralized project teams, driving performance metrics, accountability, and clarity of roles and expectations.
- Regulatory Compliance: Audit complex Medicare Part D grievance cases for 100% alignment with CMS regulations and internal compliance standards.
Coordinator, Complaint & Appeals
Aetna / CVS Health
Remote
05.2023 - 12.2025
- Claims & Appeals Resolution: Leveraged deep working knowledge of problem solving to resolve intricate provider grievances, authorization errors, and clinical coding appeals using MHK, Medcompass, and CLI databases.
- Stakeholder Collaboration: Led cross-functional alignment meetings with business partners and subject matter experts (SMEs) to isolate processing errors and map out long-term remediation workflows.
- Progress Tracking & Communication: Maintained continuous engagement with internal and external project teams via structured emails and ad-hoc meetings to clarify responsibilities and keep goals aligned.
- Status Management: Utilized tracking software (including Quickbase records and statuses) to monitor case progress and capture real-time feedback from business owners.
Customer Service Representative
Aetna Better Health Medicaid
Remote
05.2022 - 05.2023
- Systemic Issue Identification Managed insurance coverage verification and benefit configurations, proactively isolating and documenting systemic data glitches to escalate to leadership.
- Stakeholder Relations Communicated routine platform and benefit updates directly to internal teams and provider networks to ensure alignment with service goals.
Verification Representative
National Health Plans & Benefit Agency
Fraser, MI
04.2020 - 05.2021
- Risk & Discrepancy Audits: Reviewed policy applications for technical errors and variances, ensuring accurate payer assignment and mitigating organizational underwriting risk.
Front Desk Receptionist
Concentra
Sterling Heights, MI
05.2020 - 09.2020
- Data Integrity Management: Controlled accurate entry of demographic and scheduling metrics into the EMR while maintaining 100% compliance with HIPAA privacy laws.
Benefit Claim Specialist
Woman to Woman Medical Center
Freehold Township, NJ
07.2008 - 12.2013
- Process Documentation: Maintained meticulous, auditable claims documentation perfectly aligned with federal ERISA guidelines and internal operating procedures.
Education
Certified Office Assistant Coursework - undefined
01.2008
High School Diploma - undefined
Edison High School
Plainfield, NJ01.2006
Skills
Conducted audits on over 200 compliance cases, achieving full regulatory alignment with CMS standards
Assisted in enhancing project delivery speed by 30%, consistently meeting corporate deadlines
Resolved 95% of high-priority provider claims on initial contact
Accomplishments
- Regulatory Audit Excellence: Audited 200+ compliance cases, ensuring 100% regulatory alignment with CMS standards.
Timeline
Senior SIU Coordinator
Aetna / CVS Health
12.2025 - Current
Coordinator, Complaint & Appeals
Aetna / CVS Health
05.2023 - 12.2025
Customer Service Representative
Aetna Better Health Medicaid
05.2022 - 05.2023
Front Desk Receptionist
Concentra
05.2020 - 09.2020
Verification Representative
National Health Plans & Benefit Agency
04.2020 - 05.2021
Benefit Claim Specialist
Woman to Woman Medical Center
07.2008 - 12.2013
Certified Office Assistant Coursework - undefined
High School Diploma - undefined
Edison High School