KERSTIN LINDH CLIFFORD
Olathe,KS
Summary
Senior healthcare operations leader with 24+ years of managed care experience most recently leading large, multi-disciplinary Medicare Appeals teams. A strong record of driving CMS STARS performance, regulatory compliance, operational excellence, and workforce transformation.
Overview
24
24
years of professional experience
Work History
LD Director, Medicare Clinical Appeals (Par & MNP)
CVS Health / Aetna
Hartford, CT
03.2023 - Current
- Led enterprise-wide appeals operations (Par Provider, Member/Non-Contracted Provider, Fast Track, IRE, ALJ). Drove inventory optimization with 99% of colleagues meeting KPI metrics across all teams. Developed and implemented a comprehensive quality management program with consistent scores >95% exceeding metrics. Maintained CMS compliance while scaling Root Cause Corrective Action to improve outcomes.
- Leveraged technology, automation, and AI to simplify workflows, reduce handoffs, strengthen vendor performance and improve member/provider experience. Proactively identified six bot automation opportunities and led end-to-end approval, partnering with technology teams to build, and deploy. Implemented enterprise automation initiatives.
- Foster a diverse, inclusive, high-trust culture with attrition less than 5% each year by translating engagement insights into action. Integrating expanded CDI representation, enhanced onboarding and training, and focused colleague recognition. Robust talent development creating future-ready, mobile workforce.
Senior Manager, Member Non-Contracted Provider Appeals (Clinical)
CVS Health / Aetna
Hartford, CT
01.2022 - 03.2023
- Managed appeals operations, consistently meeting inventory, productivity, quality, and compliance targets.
- Drove 4-STAR appeals timeliness and accuracy across Member and Non-Contracted appeals for all contracts.
- Served as a trusted operational partner, identifying risks, driving improvements, and ensuring timely, compliant case completion.
- Built strong cross-functional partnerships to close performance gaps and deliver sustainable results.
Supervisor, Par Provider Appeals
CVS Health / Aetna
Hartford, CT
12.2020 - 01.2022
- Managed daily operations for the Par Provider appeals team with a focus on Medical Policy Operations (MPO).
- Led teams through technology and workflow changes while partnering across functions to meet operational and compliance objectives.
Supervisor, Fast Track Appeals
CVS Health / Aetna
Hartford, CT
09.2017 - 12.2020
- Responsible for day-to-day operations for the Medicare Advantage Fast Track Appeals team.
- Directed multiple platform transitions and process changes while maintaining performance, quality, and compliance standards.
UM Nurse Consultant
Aetna / Coventry Health
Hartford, CT
05.2002 - 09.2017
- Delivered utilization and complex case management for Medicare and Commercial members across the continuum of healthcare settings.
- Served as trainer and subject matter expert across UM teams; applied InterQual, MCG, Milliman, and CMS guidelines to ensure appropriate, compliant care.
Education
Master of Business Administration (MBA) -
Baker University
Bachelor of Science in Nursing (BSN) - undefined
Rockhurst College / Research College of Nursing
Registered Nurse - Active License
Certified Professional Coder - Apprentice
Skills
- Operational Excellence
- Change Management
- Continuous Improvement
- Innovation
- Colleague Development / Engagement
- Inclusive Leader
Timeline
LD Director, Medicare Clinical Appeals (Par & MNP)
CVS Health / Aetna
03.2023 - Current
Senior Manager, Member Non-Contracted Provider Appeals (Clinical)
CVS Health / Aetna
01.2022 - 03.2023
Supervisor, Par Provider Appeals
CVS Health / Aetna
12.2020 - 01.2022
Supervisor, Fast Track Appeals
CVS Health / Aetna
09.2017 - 12.2020
UM Nurse Consultant
Aetna / Coventry Health
05.2002 - 09.2017
Bachelor of Science in Nursing (BSN) - undefined
Rockhurst College / Research College of Nursing
Master of Business Administration (MBA) -
Baker University
Registered Nurse - Active License
Certified Professional Coder - Apprentice