BAILEY CLEMONS
Oshkosh
Summary
Medicare Compliance and Appeals Analyst with a proven track record of maintaining 96–98% quality scores in high-volume, regulated environments. Expertise in second-level appeals, audit analysis, and process improvement initiatives that reduce risk and enhance operational performance. Skilled in translating complex CMS regulations into actionable insights, developing data-driven reports, and leading training initiatives. Recognized as a trusted SME who drives consistency, compliance, and cross-functional alignment.
Overview
6
6
years of professional experience
Work History
Senior Medicare Compliance and Appeals Analyst
Humana
07.2025 - Current
- Conduct comprehensive second-level Medicare appeal reviews on 30+ cases weekly to ensure regulatory compliance with CMS guidelines and internal quality standards while maintaining a quality score of 96%
- Serve as a subject matter expert (SME), providing cross-functional guidance that ensures consistent regulatory interpretation and accurate case resolution.
- Analyze audit findings to identify risk trends, leading to process improvements that enhanced compliance accuracy and reduced operational risk.
- Regularly train new hire classes of 10-15 associates on appeal processes, enhancing team efficiency and knowledge retention.
- Develop Excel-based performance reports improving leadership visibility into compliance metrics and operational trends.
Medicare Compliance and Appeals Analyst
Humana
05.2024 - 07.2025
- Conducted comprehensive reviews of 40+ expedited Medicare appeals and coverage denials to ensure compliance with CMS regulations and internal quality standards while maintaining a quality score of 98%.
- Successfully manages relationships with senior leaders and peers and can influence a diverse group through effective communication and strong interpersonal skills.
- Prepared detailed appeal summaries and compliance reports highlighting trends, root causes, and opportunities for operational improvement.
- Developed structured Excel reports consolidating multi-source data to support leadership visibility into appeal outcomes and quality performance metrics.
Senior Customer Service Representative
United Healthcare
07.2022 - 04.2024
- Investigated and responded to over 30 customer service escalations a day.
- Collaborated with cross-functional teams to streamline communication and enhance service delivery.
- Demonstrated excellent multitasking abilities by managing multiple concurrent tasks while ensuring timely completion.
Medical Front Office Manager
Louisiana Orthopedic Specialists
08.2021 - 07.2022
- Effectively managed patient scheduling, registration and billing processes with a focus on accuracy and efficiency.
- Trained and supervised new staff, providing orientation and training for new practices and procedures.
- Developed policies and procedures related to the daily operations of the medical office that helped to reduce wait times by an average of 15 minutes per patient.
- Created reports summarizing daily activities using Microsoft Excel software.
Customer Care Supervisor
Lafayette Veterinary Care Center
04.2021 - 08.2021
- Implemented problem-solving techniques to identify root causes of customer issues and provide appropriate solutions.
- Successfully managed high call volumes (40-50 per day) while maintaining quality assurance standards.
- Assisted in the preparation of presentations using PowerPoint and Excel spreadsheets.
- Collaborated with cross-functional teams on initiatives that drive positive customer experiences.
Patient Accounts Professional
Ochsner Lafayette General
12.2020 - 04.2021
- Implemented problem-solving techniques to resolve complex billing issues quickly and efficiently.
- Conducted quality assurance audits on 15-20 accounts daily ensuring compliance with applicable regulations.
- Prepared daily summary reports detailing status of pending claims, payments received, total rejections and adjustments made per payer.
Medical Office Assistant
Ochsner Lafayette General
03.2020 - 12.2020
- Organized large volumes of patient data and medical documents for easy retrieval in busy 6 provider clinic.
- Provided excellent customer service by answering phones, responding to emails, scheduling appointments, addressing patient inquiries and concerns.
- Identified opportunities for process improvement to enhance patient satisfaction.
Education
High School Diploma -
Chalmette High School
Chalmette, LA05-2015
Skills
- Medicare Appeals & Grievances
- CMS Guidelines
- Regulatory Compliance
- Audit & Risk Analysis
- Excel Reporting
- Data Analysis
- Quality Metrics Development
- Performance Tracking
- Process Improvement
- Training & Development
- Cross-Functional Collaboration
- Issue Resolution
- Customer service and support
- Team leadership
Accomplishments
- Maintained 96–98% quality scores across high-volume Medicare appeals environments
- Trained and onboarded multiple classes of 15–20 employees, improving team performance and consistency
- Developed Excel-based reporting tools that enhanced leadership visibility into compliance metrics
- Identified audit trends and implemented process improvements that reduced operational risk and inefficiencies
Timeline
Senior Medicare Compliance and Appeals Analyst
Humana
07.2025 - Current
Medicare Compliance and Appeals Analyst
Humana
05.2024 - 07.2025
Senior Customer Service Representative
United Healthcare
07.2022 - 04.2024
Medical Front Office Manager
Louisiana Orthopedic Specialists
08.2021 - 07.2022
Customer Care Supervisor
Lafayette Veterinary Care Center
04.2021 - 08.2021
Patient Accounts Professional
Ochsner Lafayette General
12.2020 - 04.2021
Medical Office Assistant
Ochsner Lafayette General
03.2020 - 12.2020
High School Diploma -
Chalmette High School