Alicia Elswick
Curran,MI
Summary
Highly analytical Senior SIU Investigative Analyst with over 10 years of specialized experience in healthcare operations, forensic auditing, and Fraud, Waste, and Abuse (FWA) detection. Proven track record in data mining complex claims data, identifying suspicious billing patterns, and conducting deep dive medical record reviews. Expert in ensuring strict compliance with CMS regulations, writing detailed investigative reports, and collaborating with Legal and Compliance teams to mitigate organizational risk.
Overview
10
10
years of professional experience
Work History
SENIOR SIU INVESTIGATIVE ANALYST
Aetna / CVS Health
Remote/Michigan
01.2025 - Current
- Lead comprehensive investigations into suspected Fraud, Waste, and Abuse (FWA) cases, utilizing advanced data mining techniques to identify high risk billing patterns and trends.
- Triage and systematically investigate internal and external FWA complaints, managing end to end case files and generating detailed investigative reports with clear findings and recommendations.
- Ensure 100% alignment with CMS regulatory frameworks, prepping and referring validated FWA cases to regulatory agencies within strict federal and state timeframes.
- Collaborate closely with cross functional partners, including Legal, Compliance, and Provider Relations, on complex ad hoc investigations and executive level reporting.
CLAIMS & CLINICAL SYSTEMS ANALYST
Aetna / CVS Health
Remote/Michigan
04.2022 - 12.2022
- Participated in complex claim and prepayment review processes, meticulously auditing medical records against billed claims to identify inappropriately billed services and potential FWA.
- Leveraged multi layered healthcare databases (MHK, Medcompass, CLI) to perform deep dive investigations into clinical coding logic, system inaccuracies, and provider reimbursement errors.
- Applied sharp attention to detail and standard industry coding guidelines (CPT, HCPCS, ICD-10) to resolve high stakes provider grievances and claims discrepancies.
CUSTOMER SERVICE REPRESENTATIVE
Aetna Better Health Medicaid
Remote/Michigan
06.2021 - 04.2022
- Gained valuable Medicaid experience while monitoring communication channels and handling high volume provider inquiries regarding complex claims, payment disputes, and policy guidelines.
- Demonstrated strong problem solving, verbal, and written communication skills to resolve complex billing issues, consistently maintaining high First Call Resolution (FCR) metrics.
VERIFICATION REPRESENTATIVE
National Health Plans & Benefit Agency
Fraser, MI
09.2020 - 06.2021
- Reviewed insurance applications and detailed data to interpret claims accuracy, identifying technical errors and potential risks to ensure compliance with payer standards.
FRONT DESK RECEPTIONIST / PATIENT REGISTRATION
Concentra & McLaren Macomb Hospital
MI
01.2016 - 01.2020
- Facilitated accurate patient registration, EMR data entry, and insurance verification, matching front end data against healthcare protocols to ensure clean, compliant claim submissions.
Education
High School Diploma - undefined
Edison High School
Plainfield, NJBusiness Technology & Office Assistant Certified Coursework - undefined
01.2008
Skills
- FWA Expertise Fraud, Waste, & Abuse (FWA) Identification, Forensic Auditing, Case Triage & Investigation, Prepayment Claim Review, Root Cause Analysis, Regulatory Referrals
- Coding & Compliance: Working knowledge of CPT, HCPCS, and ICD 10 guidelines, Clinical Coding Accuracy, Medical Record Review, CMS Regulations, Medicare Part D, HIPAA
- Systems & Databases: QuickBase, Epic EMR, MHK, Medcompass, CLI, Advanced Excel (VLOOKUPs, Pivot Tables), Data Mining & Visualization
Timeline
SENIOR SIU INVESTIGATIVE ANALYST
Aetna / CVS Health
01.2025 - Current
CLAIMS & CLINICAL SYSTEMS ANALYST
Aetna / CVS Health
04.2022 - 12.2022
CUSTOMER SERVICE REPRESENTATIVE
Aetna Better Health Medicaid
06.2021 - 04.2022
VERIFICATION REPRESENTATIVE
National Health Plans & Benefit Agency
09.2020 - 06.2021
FRONT DESK RECEPTIONIST / PATIENT REGISTRATION
Concentra & McLaren Macomb Hospital
01.2016 - 01.2020
High School Diploma - undefined
Edison High School