Sheynette Hayes
Jacksonville
Summary
Case Management & Appeals Quality professional with 15+ years in health plan operations, specializing in end-to-end case handling, Medicare appeals, quality auditing, and compliance. Proven ability to triage, investigate, and resolve complex member cases; coach and mentor teams; and drive process improvements through data-driven analysis and corrective actions. Experienced liaison across clinical, claims, quality, and vendor partners to ensure timely, accurate, and compliant case outcomes.
Overview
20
20
years of professional experience
Work History
Appeals Quality Auditor Lead
Centene Corporation
02.2022 - Current
- Conduct case reviews on routine and complex Medicare appeal files to ensure accuracy and regulatory compliance.
- Support staff in managing complex appeal cases by providing clarification, case direction, and escalation handling.
- Document and communicate case audit findings to support continuous improvement.
- Deliver targeted training and mentorship on unfavorable audit scores.
- Assist auditors with complicated case files, ensuring proper interpretation of case facts and policies.
- Perform monthly case quality evaluations for compliance and consistency.
- Generate daily/weekly assignment and productivity reports to support caseload monitoring.
Client Advocate
Aetna/CVS
10.2021 - 02.2022
- Managed escalated member cases from intake through resolution.
- Served as primary point of contact for complex case inquiries and provided Plan Sponsor communication.
- Coordinated with internal teams to align case resolutions with plan requirements.
- Identified trends in escalations and recommended actions to prevent recurrence.
Senior Complaint & Appeal Analyst
Aetna/CVS
10.2018 - 09.2021
- Managed end-to-end handling for complaints and appeals, researching case-specific data and claims logic.
- Executed internal quality audits on vendor-managed cases.
- Provided case consultation and mentoring to offshore partners.
- Analyzed data for case corrections and escalations.
- Served as point of contact for incoming electronic cases.
Complaint & Appeal Analyst
Aetna/CVS
09.2010 - 10.2018
- Delivered full-lifecycle case management for appeals, grievances, and complaints.
- Researched claims processing logic, eligibility, and payment data.
- Identified trends and recommended improvements.
- Created training materials and supported onboarding of new staff.
Customer Service Representative
Aetna
11.2005 - 09.2010
- Handled member cases involving benefits, claims reviews, appeals intake, and pre-authorizations.
- Explained members' rights and clarified plan provisions.
- Routed and tracked appeal and pre-authorization cases.
Education
Bachelor of Science - Psychology
Liberty University
Lynchburg, VA12-2024
Associate of Arts - Sociology
Florida State College
Jacksonville, Florida01-2012
Skills
- Case Intake, Triage & Lifecycle Management
- Medicare Appeals & Grievances
- Quality Auditing & Compliance
- Documentation Integrity
- Complaint Resolution
- Root Cause Analysis
- Training & Mentorship
- Data Analysis
- Cross-Functional Collaboration
Timeline
Appeals Quality Auditor Lead
Centene Corporation
02.2022 - Current
Client Advocate
Aetna/CVS
10.2021 - 02.2022
Senior Complaint & Appeal Analyst
Aetna/CVS
10.2018 - 09.2021
Complaint & Appeal Analyst
Aetna/CVS
09.2010 - 10.2018
Customer Service Representative
Aetna
11.2005 - 09.2010
Bachelor of Science - Psychology
Liberty University
Associate of Arts - Sociology
Florida State College