Mercedes Taylor
Fairfield,CA
Summary
Detail-oriented Compliant, Appeals, and Grievance Coordinator with 19 years of experience in managing member complaints, appeals investigations, and regulatory compliance within a healthcare environment. Skilled in case documentation, cross-department coordination, and ensuring adherence to CMS and state regulatory timelines. Proven ability to resolve complex member issues while maintaining accuracy, confidentiality, and high service standards.
Overview
19
19
years of professional experience
1
1
Certification
Work History
COMPLAINT AND APPEALS ANALYST
Aetna
01.2016 - Current
- Responsible for reviewing, investigating, and resolving assigned member grievance and appeal cases
- Manage and document all assigned casework thoroughly, accurately, and timely per CMS and Aetna guidelines
- Identify trends and emerging issues and report and recommend solutions
- Work independently to investigate, research, review, and resolve complex, high level member grievances, reconsiderations and expedited concerns within regulated timeframes.
- Research, resolve and communicate the outcome for all member complaints and appeals which can include verbal and written correspondence.
- Documents all casework (both written and verbal) accurately, thoroughly, and timely
- Work in a fast-paced environment to oversee the resolution of appeals meeting turnaround time and the internal and external regulatory guidance
- Responsible for serving as the point of contact for the appeal if there is an inquiry from leadership, compliance and State regulators
PROVIDER SERVICE REPRESENTATIVE/CREDENTIALING
Aetna
01.2007 - 01.2016
- Maintained accurate provider database and documentation to ensure compliance with regulations.
- Entered new physician contracts promptly to support operational efficiency.
- Resolved escalated provider inquiries through detailed research within contract guidelines.
- Educated providers on updated protocols, policies, and procedures for improved understanding.
- Conducted non-medical research, including eligibility verification and benefits checks.
- Handled inquiries from Medicare Advantage members via inbound calls and written correspondence.
- Navigated multiple systems to resolve complex issues for members and providers efficiently.
- Documented required information meticulously to meet risk management and accreditation standards.
Education
Bachelor Degree - Business Administration
University of Phoenix
09.2026
Skills
- Attention to detail
- Problem solving
- Communication skills
- Critical thinking
- Organizational skills
- Time management
- Multitasking
- Team leadership
- Written communication
- Proficient experience in Microsoft Word, Excel, Access, Outlook, and Powerpoint
Certification
- Medical Terminology
- Project Management
Timeline
COMPLAINT AND APPEALS ANALYST
Aetna
01.2016 - Current
PROVIDER SERVICE REPRESENTATIVE/CREDENTIALING
Aetna
01.2007 - 01.2016
Bachelor Degree - Business Administration
University of Phoenix