Tanika Taylor
New Kensington,PA
Summary
Experienced professional overseeing appeals and grievance processes, ensuring efficient operational management with a focus on execution and continual improvement. Developed and maintains a Provider Dispute Resolution Process, implementing policies and procedures to ensure compliance with regulations. Skilled in analyzing data for process improvements. Focused on maximizing resource utilization to support scalable operations and increase bottom-line profitability. Organized and systematic with natural relationship-building and leadership talents.
Overview
23
23
years of professional experience
1
1
Certification
Work History
Director, Grievance & Appeals, DHS Fair Hearing Coordinator, Critical Incident & Rapid Response
PA Health & Wellness
Pittsburgh
06.2021 - Current
- Responsible for oversight of appeals and grievance processes critical incidents and quality of care
- Directs and ensures the efficient operational management of appeals and grievance department/ function with emphasis on execution, outcomes, continual improvement, and performance enhancement
- Responsible for oversight informal and formal processes for settlement of Provider Disputes and Provider Appeals
- Developed, implemented, and maintains a Provider Dispute Resolution Process that provides for the informal resolution of Provider Disputes
- Designs and implements processes, policies, trainings, and procedures to ensure compliance with new and existing regulations
- Addresses areas of below-standard performance and implements mechanisms to bring performance up to standard
- Tracks and trends preventable appeals and grievances and presents findings to Operations leadership
- Minimizes legal and financial risk by taking appropriate measures to protect the interest of members and providers
- Identifies need for in-house legal involvement on sensitive cases, and coordinates with plan attorneys on litigated cases, helping to oversee case preparation and research
- Provides fiscal management and support including developing operation budgets and completing forecasts and variance reporting
- Ensures appropriate systems and technology are in place to meet compliance, quality, and operational efficiency measures for the department/ function
- Analyze data regularly to identify and implement process improvements
- Coordinates grievance/appeal committee meeting with appropriate parties
- Establishes and maintains cohesive relationships with internal partners
- Evaluate compliance policies and procedures and analyze/recommend enhancement
- Produced tracking and trending to senior leadership for OLTL calls
- Perform data analysis from Micro-Strategy to progress metrics, assisted with OLTL reporting on monthly basis
- Dedicated OLTL (state) escalation liaison on researching and resolving claim disputes for provider/claims issues.
Director of Operations
PA Health & Wellness
Pittsburgh
10.2019 - 06.2021
- Responsible for oversight of Resolutions (call center) & Rapid Response Team, 3 managers, 7 supervisors, 2 work force analyst and responsible for 150+ team members overall
- Develop, implement, and monitor day-to-day operational systems and processes that provide visibility into goals, progress, and obstacles for our key initiatives
- Plan, monitor, and analyze key metrics for the day-to-day performance of the operations to ensure efficient and timely completion of tasks
- Defining, implementing, and revising operational policies and procedures for accomplishing the organization and department’s objectives and to ensure compliance with all related laws, regulations and executive orders
- Collaborate with HR and leadership team in the development of performance goals and long-term operational plans
- Set strategic goals and action plans for operational efficiency and increased productivity and quality standards
- Maximize efficiency and productivity through extensive process analysis and interdepartmental collaboration
- Analyze current operational processes and performance, recommending solutions for process improvements.
Operations Manager (Resolutions & Rapid Response Escalation Team)
PA Health & Wellness
Pittsburgh
08.2018 - 10.2019
- Support and lead operation management in the implementation of operation strategy, talent acquisition, change initiatives, productivity, and staffing
- Ensure operation integrity, including compliance with all policies and procedures
- Managing relationships with provider partners to promote and maintain a positive engagement
- Dedicated OLTL escalation liaison on researching and resolving claim disputes for provider/claims issues
- Project Manage work teams to accomplish full resolution such as: Provider Data Management, Provider/Claims RRT, consistent work team engagement and productivity, meeting facilitation, consensus building and implementation oversight
- Encourage a positive work environment and culture for all team members
- Manage team of 3 managers, 7 supervisors, 2 work force analyst and responsible for 150+ team members to oversee their growth and development within organization as well as their teams
- Analyzes call center performance reports by collecting, reviewing, and summarizing data and trends
- Very passionate to strive to meet organization goals by taking ownership for undertaking new and different requests and exploring opportunities that may add value to job goals & accomplishments
- PHW Business Continuity Owner.
Program Coordination Supervisor
PA Health & Wellness
Pittsburgh
10.2017 - 08.2018
- Collaborated and contributed to building processes and procedures of Program Coordination Unit for PA Health & Wellness Go Live 1/1/18
- Manage daily operations of Program Coordination Resolution Team, ensuring adherence with policies and procedures
- Work cross-functionally across departments to guarantee achievement of quality and participant/provider satisfaction
- Identify opportunities for process improvements necessary to facilitate department functions
- Serve as a main point of contact for participant/provider complaints and escalations (SWAT escalations)
- Engages and inspires staff to exceed goals via clear, transparent communication and effective one-on-one team interactions
- Builds and maintains relationships with key stakeholders within and outside the organization including senior leadership
- Coaches and develops Program Coordination Staff to become more effective in their ability to provide outstanding participant/provider services
- Assisted with hiring process, developed performance expectations, produced training materials, investigated complaints and performance concerns, and resolved escalated participant and provider issues
- Conducts regular coaching’s, one-on-ones and feedback sessions with Program Coordination staff to improve their ability to handle and resolve all call types
- Ensures that daily/weekly/monthly call volume targets are being met
- Analyze problematic occurrences and provide solutions to ensure company compliance and growth
- Evaluate compliance policies and procedures and analyze/recommend enhancement
- Produced tracking and trending to senior leadership for OLTL calls
- Perform data analysis from Micro-Strategy to progress metrics, assisted with OLTL reporting on monthly basis
- Monitored and implemented SMEs for Transportation and Pharmacy effectiveness to ensure participants received quality service and collaborating with senior leadership to establish and implement policies & procedures.
Call Center/Care Connect Supervisor (Woman’s Health OB/GYN)
Allegheny Health Network
Pittsburgh
01.2016 - 10.2017
- Manages Women’s Health OB/GYN Pod, overseeing (12) Women Health Practices and team specializing in Gynecological Oncology
- Before transferring to Women’s Health managed two Primary Care Physicians teams of season and new onboarding agents
- Monitor all Primary Care Physicians within Allegheny Health Network
- Monitors QA results to evaluate and educate to ensure improved agent performance in accordance to standards and adherence to protocol
- Use experience and expertise to identify trends within discrepancy log to proactively correct issues before they escalate
- Monitors agents’ attendance and call adherence and responds quickly to findings
- Manages staff by generating and interpreting quality assurance and productivity reports
- Work collaboratively with management/training to formulate solutions to enhance agent performance
- Excellent customer service skills; excellent verbal and written communication skills
- Provide Monthly 1:1’s and coaching’s to ensure exceptions of team member is met
- Provide Mid-Year, Yearly Reviews and Quarterly Incentive progress reports and payout allocation
- Reviews calls for trends, ensuring agent provided exceptional customer service and followed policies, procedures, and regulatory compliance
- Provide written and verbal feedback/coaching’s
- Set goals for the team and provide written and verbal feedback/coaching’s to ensure achievement
- Manage agents’ payroll
- Monitor and evaluate agents’ performance to assure professionalism, courtesy, empathy and identify actions that can improve overall call quality.
Medicare Compliant and Appeals Supervisor
Aetna
Pittsburgh
10.2011 - 01.2016
- Responsible for the day-to-day management of staff to ensure effective resolution of member and provider/practitioner complaints/appeals
- Identifies trends involving non-clinical and clinical issues and recommends solutions
- Responsible for organization and development of high performing teams to ensure timely, customer focused response to appeals
- Oversees all new training teams at the Pittsburgh site (office based and work at home)
- Responsible for day-to-day implementation of Aetna's complaints and appeals policies and procedures
- Accountable for meeting the operational and quality objectives of the unit
- Promote collaborative relationships with internal and external constituents, which includes regular interaction with Medical Directors, Pharmacists, Medicare Compliance, Aetna Legal and the department Management team
- Provide monthly 1:1’s and coaching to ensure exceptions of team member is met
- Provide Mid-Year, Yearly Reviews and Quarterly Incentive progress reports and payout allocation
- Manage Compensation Planning tool for entire team
- Provide high quality reports to upper management
- Forecast reports to ensure team remain compliant within CMS guidelines and timeframes
- Conduct interviews for potential new employees
- Make final decisions of hiring process
- Identifies and develops diverse talent to maximize performance and achieve individual and organizational goals
- Build strong and trusting relationships with team as a whole team and individual relationships
- Conduct bi-weekly team meetings and daily management meetings
- Review teams’ final resolutions of IRE Maximus Cases and Overturns within the Part C Member Appeals Unit
- Quickly and effectively adapts to the changing demands of the environment.
Medicare Operations Customer Service Supervisor
Aetna
Pittsburgh
10.2011 - 10.2012
- Manage staff of 15 in Customer Service, Inbound & Outbound Calls
- Lead & assist with upper management projects critical to the business (Orientation Calls, First Claims, Pharmacy Address Verification)
- Handle escalated calls
- Team Development
- Ensure daily operations and workflow of the office
- Provide coaching and training to team members
- Expedite, research, and resolve complex issues
- Constantly performs established performance metrics, such as quality, production; average handling time (AHT)
- Provides Mid-Year, Yearly and Quarterly Incentive progress reports
- Strong organizational skills
- Have strong customer service experience.
Program Supervisor
CVS Caremark/TheraCom
Monroeville
06.2009 - 10.2011
- Assisted with launching 4 new therapy programs
- Manage staff of 32 in Benefit Investigations, Customer Care, Inbound Calls, Outbound Calls and Data Entry
- Conduct interviews for potential new employees
- Made final decision of hiring process
- Ensure the daily operations and workflow of the office
- Interface with patients to assess immediate needs
- Train newly hired personnel to perform in the capacity and manner expected by the company
- Reconciled billing issues between insurance companies and the patients
- Handle escalated calls
- Cross-trained in other areas and therapies, proficient in training new employees, and responsible for upper management reports
- Maintains database of patient, insurance and physician information providing clear and concise documentation that may be available to both internal and external resources
- Manages the ability to work with non-profit patient assistance programs that provides financial assistance with patient’s co-pays
- Manages customer-service in a healthcare office setting supporting insurance inquiries, benefits verification, pre-authorization, or related insurance billing
- Maintain confidentiality regarding corporate business practices
- Produce daily and weekly reports internally and for manufacture.
General Liability Adjuster
Giant Eagle, Inc.
Pittsburgh
09.2006 - 06.2009
- Investigate claims by interviewing claimant, operations personnel, or third-party witness to determine case facts
- Currently handle all Slip & Fall incidents and back-up for Pharmacy/Fleet incidents
- Evaluate investigation within applicable legal principles to assess liability and identify responsible parties
- Maintain documentation of investigations, interviews, or other relevant material in accurate and timely manner
- Assess potential case value within applicable guidelines; negotiate settlements of minor-moderate claims with claimant and/or counsel
- Identify and notify potentially responsible 3rd parties of exposure
- Set initial reserve within 30 days, monitor, and adjust as necessary
- Provide Arbitration or Trial testimony as required
- Act as resource to Operations on risk prevention within established area of responsibility
- Participate in claim meetings and maintain familiarity with applicable legal concepts
- Keep Operations personnel apprised of claim status and resolution.
Claims Technician
UPMC Work Partners
Pittsburgh
10.2001 - 08.2006
- Retrieve incidents reports and enter information in database
- Receive medical reports and determine acceptance or denial
- Decide determination of Compensability
- Creates FROI (First Report of Injury) and send to Bureau
- Maintain deadline of Bureau Documents
- Maintain Auto-Diaries to be utilized to assist in claims management
- Investigation and recognition of subrogation potential
- Creates LT packages (Lost time)
- Pay medical bills and enter codes
- Handle all Incident and Medical Only Claims
- Prepare Restricted Medical Only and Lost Time Claims
- Enter notes regarding claimants’ medical documentation
- Receives, Sort, Label, File, and Retrieves Documents and Bills
- Answered questions regarding benefits, such as, billing questions and claim status.
Education
Associate Degree - Information Technology, Networking Administration
RETS Institute of Technology
Monroeville, PA03.2003
Skills
- CMS
- VM Ware
- NICE
- EPIC
- Athena
- MapAPP
- AIM
- SalesForce
- Geospacial
- SharePoint
- Kronos
- PRISM
- Eservice
- Citrix
- Advance PCS
- RiskMaster World
- Compliant and Appeals Tracking Systems
- Omni Forms
- PDF Forms
- FROI forms
- Aetna Strategic Desktop
- E2I
- IOP View
- Medicare Intake Database
- Public Relations
- Business Portal
- MedHok
- TruCare
- Omni
- CenProv
- Taleo Emdeon
- Amisys
- Portico
- CMS Supervisor
- CenPas
- UMV
- FileNet
- Micostrategy
- PRIME
- RxAdvance
- Promise
- Leadership and Involvement
- Decision-Making
- Team Development
- Call Center Operations
- Policy Enforcement
- Team Building and Leadership
- Customer Relationship Management (CRM)
- Talent Allocation
- Workforce Management
- Training and mentoring
- Financial Acumen
- Operational leadership
Accomplishments
- PA Health & Wellness Business Continuity Owner 2019 - 2022
- PHW backup Liaison for State (OLTL)
- Built Rapid Response team for State, Legislative and Executive Complaints
- PA Health & Wellness DEI Co-Chair
- INSPIRE Co-President Centene Corporation (Enterprise)
- INSPIRE Chair local chapter / INSPIRE Mentor
- Member MOSAIC & cPRIDE (Corporate and local chapter)
- Greater St. Louis Black Diversity The Fellows Experience 2023/2024
- PA Health & Wellness Courageous Conversations Facilitator
- RECI Racial Equity Consciousness Facilitator – Certified
- Black Leadership Academy's Management Accelerator - Certified
- Theme Team Committee Member/ Walk A Mile Lead (WAM)
- Led Food Drive Initiative
- Park Place African Methodist Episcopal Church helped supply 3,000 families with food and other pantry items
- Harvard Woman’s Leadership 2024
Certification
- RECI Racial Equity Consciousness Facilitator
- Black Leadership Academy's Management Accelerator
Timeline
Director, Grievance & Appeals, DHS Fair Hearing Coordinator, Critical Incident & Rapid Response
PA Health & Wellness
06.2021 - Current
Director of Operations
PA Health & Wellness
10.2019 - 06.2021
Operations Manager (Resolutions & Rapid Response Escalation Team)
PA Health & Wellness
08.2018 - 10.2019
Program Coordination Supervisor
PA Health & Wellness
10.2017 - 08.2018
Call Center/Care Connect Supervisor (Woman’s Health OB/GYN)
Allegheny Health Network
01.2016 - 10.2017
Medicare Operations Customer Service Supervisor
Aetna
10.2011 - 10.2012
Medicare Compliant and Appeals Supervisor
Aetna
10.2011 - 01.2016
Program Supervisor
CVS Caremark/TheraCom
06.2009 - 10.2011
General Liability Adjuster
Giant Eagle, Inc.
09.2006 - 06.2009
Claims Technician
UPMC Work Partners
10.2001 - 08.2006
Associate Degree - Information Technology, Networking Administration
RETS Institute of Technology
- RECI Racial Equity Consciousness Facilitator
- Black Leadership Academy's Management Accelerator
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