Keosha Banks-Pringle
Madera,,CA
Summary
Dynamic and detail-oriented Senior Operations Manager with extensive experience managing Medicare appeals operations and ensuring compliance with state and federal laws, CMS regulations, and accrediting agency standards. Proven ability to develop and implement policies, procedures, and workflows that enhance operational efficiency, streamline processes, and resolve complex appeals issues. Adept at leading cross-functional teams, collaborating with legal counsel, internal departments, and external regulatory agencies to ensure seamless operations and regulatory compliance. Recognized for strategic planning and project management capabilities, consistently delivering solutions that drive operational efficiency and reduce costs. Skilled in problem-solving and process improvement, with a focus on optimizing business performance and achieving organizational objectives.
Overview
11
11
years of professional experience
Work History
Senior Manager Medicare Appeals Operations
CVS Health
01.2023 - Current
- Manage administrative operations for the Pre-service and Fast-Track appeals teams, ensuring efficient case handling and compliance with established timelines, resulting in improved appeal turnaround times and a consistent 98% compliance rate with CMS standards.
- Coordinated with internal departments to ensure successful execution of projects according to timeline and budget constraints.
- Directed cross-functional teams in developing innovative solutions to complex problems, which led to the reduction of backlogged inventory by 90% across both lines of business
- Developed and implemented strategies to improve operational efficiency, reduce costs, and increase productivity, leading to a 60% reduction in overtime and an increased same-day launch rate of 40%.
- Managed crisis situations, implementing contingency plans to minimize impact on operations, successfully mitigating disruptions during staffing shortages, and ensuring continued compliance with regulatory requirements.
- Guided change management initiatives to ensure smooth adoption of new business practices.
Supervisor Complaints and Appeals Operations
CVS Health
05.2020 - 01.2023
- Provided strategic oversight for the Medicare Pre-service Part C/Part B Appeal teams, effectively managing a team of 25+ associates to ensure the timely and accurate resolution of member and provider/practitioner complaints and appeals.
- Acted as a liaison between upper management and staff, facilitating open communication.
- Audited company's legal documents to verify compliant policies and procedures.
- Developed and implemented operational policies and procedures to ensure efficiency and accuracy of workflows.
Senior Complaint and Appeal Analyst
Aetna
10.2018 - 05.2020
- Accountable to leadership to support the day-to-day management of staff and operational functions of the team as a collective in a demanding environment with strict regulatory guidelines and deadlines.
- Assisted in developing a comprehensive database management system.
- Identified areas for improvement, narrowing focus for decision-makers in making necessary changes.
- Oversaw quality control to identify inconsistencies and malfunctions.
Complaint and Appeal Analyst
Aetna
06.2013 - 10.2018
- Coordinate effective resolution of member or provider/practitioner appeals.
- Subject matter expert and independently coached others on complaints and appeals, ensuring compliance with federal and state regulations.
- Manage and control trend inventory, independently investigate, change, or revise policy to resolve the most escalated cases from broad, internal, and external constituents for all products and issues.
Education
Associate in arts - Criminal Justice
Kaplan College
Skills
- Complaints and Appeals Management
- State and Federal Compliance
- Corporate Governance
- Adherence to policies and procedures
- External Regulatory Agencies
- Medicare guidelines
- Compliance and Legal Counsel Collaboration
- Data Analytics & Forecasting
- Process Optimization
- Business Operations
- Strategic Planning
- Project Management
- Stakeholder Engagement
- Budget Management
References
References upon request
Timeline
Senior Manager Medicare Appeals Operations
CVS Health
01.2023 - Current
Supervisor Complaints and Appeals Operations
CVS Health
05.2020 - 01.2023
Senior Complaint and Appeal Analyst
Aetna
10.2018 - 05.2020
Complaint and Appeal Analyst
Aetna
06.2013 - 10.2018
Associate in arts - Criminal Justice
Kaplan College
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