Sheynette Hayes
Jacksonville
Summary
I am an experienced, versatile, and results-oriented professional Health Insurance Specialist with proven expertise in handling and resolving claim disputes, escalated claim issues, quality audits, and excellent written and verbal customer service. A collaborative individual, I successfully lead others by providing training, internal audits, and mentoring to new hires, fostering a team-oriented culture.
Overview
18
18
years of professional experience
Work History
Appeals Quality Auditor Lead
Centene Corporation
02.2022 - Current
- Manage routine and complex quality audits in Medicare appeals using a specific audit tool and databases to verify the accuracy and thoroughness adhering to departmental procedures, regulations, and documented guidelines of randomly selected appeals.
- Owner of my team's internal resource (Frequently Asked Questions/FAQ) which includes links to all published EBOS job aids.
- This allows the Quality Audit team to have ready access to the source of truth when auditing.
- I regularly coordinate with my partner to ensure the document is updated and published correctly.
- Support my team in answering questions, handling escalations, team engagement by performing check-ins with my team to establish an open floor to discuss issues or concerns, and I monitor two quality audit tools, (Agency Packet Review and Docs Needed).
- Document and report findings from individuals and team audits.
- Responsible for sending daily morning and end of day emails to report daily stats.
- Provides training and mentoring regarding unfavorable audit scores as needed.
- Supports Quality Auditors with questions and complex files.
- Perform monthly audits on the Quality Auditors.
- Assist with special projects delegated by Management.
Client Advocate
Aetna/CVS
10.2021 - 02.2022
- Functioned as a single-point-of-contact for escalated member level issues via email, may include requests for claim analysis, benefit questions and plan clarification, verification and updates to terminations, hire/re-hire dates, and correction of enrollment errors.
- Resolved escalations and communicates resolution to the Plan Sponsor, including action steps for long term solution, if necessary.
- Collaborated with Account Management team to achieve growth/renewal objectives and meet customer expectations.
- Initiated and maintains partnerships with other departments throughout the organization.
- Ability to work with cross-functional business units to meet customer needs; promotes collaboration among constituents and represents a professional image of the company.
Senior Complaint and Appeal Analyst
Aetna/CVS
10.2018 - 10.2021
- Performed internal quality audits for Offshore vendor partners.
- Mentored and answered inquiries from our Offshore vendor partners concerning Complaint and Appeal policy guidelines.
- Reviewed data analytics for case corrections and escalations by identifying trends and recommending solutions.
- Assisted with Special Projects for Inventory reductions.
- Performed Member outreach calls.
- Researched and resolved incoming electronic complaints/appeal as appropriate as a "single-point-of-contact" based on type of appeal.
- Identified and rerouted inappropriate work items that do not meet complaint/appeal criteria as well as identify trends in misrouted work.
- Researched standard plan design, certification of coverage and potential contractual deviations to determine the accuracy and appropriateness of a benefit/administrative denial.
- Reviewed clinical determinations and understood rationale for decision.
- Able to research claim processing logic and various systems to verify accuracy of claim payment, member eligibility data, billing/payment status, and prior to initiation of the appeal process.
- Served as point person for newer staff in answering questions associated with claims/customer service systems and products.
Complaint and Appeal Analyst
Aetna/CVS
10.2010 - 10.2018
- Responsible for intake, investigation and resolution of appeals, complaints, and grievances for all commercial products.
- Ensured timely, customer focused response to appeals, complaints and grievance.
- Identified trends and emerging issues and report and recommend solutions.
- Researched incoming electronic complaints/appeals.
- Identified and rerouted inappropriate work items that do not meet complaint/appeal criteria.
- Researched claim processing logic to verify accuracy of claim payment, member eligibility data, billing/payment status, prior to initiation of appeal process.
- Responsible for coordination of all components of complaints/appeals including final communication to member/provider for final resolution and closure.
- Served as a technical resource to my colleagues on claim research, letter content, state or federal regulatory language, triaging of complaint/appeal issues, and similar situations requiring a higher level of expertise.
- Identified trends and emerging issues and reported my input on potential solutions.
- Followed up to assure complaint/appeal were handled within established time frame to meet company and regulatory requirements.
- Act as single point of contact for the Executive complaints and appeals and Department of Insurance, Department of Health or Attorney General complaints or appeals on behalf of members or providers, as assigned.
- Developed training materials for new hires.
Customer Service Representative
Aetna
11.2005 - 10.2010
- Demonstrated excellent communication skills, both verbal and written, in order to effectively interact with customers.
- Explained member's rights and responsibilities in accordance with member's health plan.
- Performed review of member claim history to ensure accurate tracking of benefit maximums and/or coinsurance/deductible.
- Managed incoming requests for appeals and pre-authorizations not handled by Clinical Claim Management.
- Displayed strong organizational skills while managing multiple projects simultaneously.
- Performed data entry tasks accurately and in a timely manner.
- Developed and maintained positive relationships with customers by providing timely, accurate information and solutions to their inquiries or problems.
Education
Completed coursework towards Associate in Arts (A.A.) in Sociology -
Florida State College of Jacksonville
Jacksonville, Florida01.2012
High School Diploma -
Samuel W. Wolfson High School
Jacksonville, Florida06.1987
Skills
- Quality Management Systems
- Decision Making
- Organizational Skills
- Customer Focus
- Internal Auditing
- Risk Assessment
- Training and Coaching
- Customer Service
- Effective Communication
- Data Collection
- Problem Solving
- Team Collaboration
- Analytical Thinking
- Interpersonal skills
- Multitasking
- Microsoft Office
References
References available upon request.
Timeline
Appeals Quality Auditor Lead
Centene Corporation
02.2022 - Current
Client Advocate
Aetna/CVS
10.2021 - 02.2022
Senior Complaint and Appeal Analyst
Aetna/CVS
10.2018 - 10.2021
Complaint and Appeal Analyst
Aetna/CVS
10.2010 - 10.2018
Customer Service Representative
Aetna
11.2005 - 10.2010
Completed coursework towards Associate in Arts (A.A.) in Sociology -
Florida State College of Jacksonville
High School Diploma -
Samuel W. Wolfson High School
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