Tessa Hayes

Managing the development of risk and compliance reports, metrics and dashboards per state/CMS guidelines within Medicaid Enrollment.

• Investigating potential compliance issues and providing recommendations to ensure regulatory compliance.
• Participating in regular risk management meetings and provide relevant updates.
• Investigating and resolving noncompliance issues in a timely manner.
• Collaborating with other departments to ensure compliance with Medicaid regulations and address identified issues and concerns.
• Assisted in the development of corrective action plans to address issues identified during audits.
• Improved risk management frameworks through continuous review and modification of existing procedures.
• Implementing risk mitigation strategies that enhanced compliance with regulatory requirements.
• Trained staff in risk management policies and monitored compliance to control company liability.
• Supported senior leadership in decision-making processes by providing timely and accurate risk analysis reports.
• Analyzed audit findings, preparing detailed reports for senior management review and strategic decision-making.

10 years experience in Medicare Enrollment providing root cause analysis and resolution for escalated issues in CMS Processing Unit department/RSO Enrollment, chosen to become apart of the Special Operations team within CPU.

• Developed and maintained strong relationships with a large network of business partners within Humana, including but not limited to Urgent Inquiry, Executive Inquiry, Medicare Billing, Medicare Supplement, Medicaid, Grievance and Appeals, Agent Retail Service Operations and Group Medicare Enrollment.
• Connected meaningfully with members to build emotional engagement and member advocacy.
• Consistently trusted with and assigned special projects and tasks by management.
• Extensive knowledge in Medicare guidelines and regulations as outlined in Chapter 2 Medicare Managed Care Manual.
• Responded to member inquiries and complaints in a courteous manner.
• Monitored changes in Medicare policies, adapting processes to maintain accuracy and compliance in enrollments.
• Supported team members in achieving departmental goals by sharing knowledge and expertise on best practices for Medicare enrollment processes.
• Delivered prompt resolution for member inquiries regarding their Medicare enrollment status, providing clear and concise information.
• Handled escalated member cases with professionalism, working diligently towards a satisfactory resolution.
• Conducted root cause analyses to identify underlying issues and provide actionable recommendations for resolution for escalated issues.
• Trained new Enrollment Representatives on departmental policies and procedures, fostering a collaborative environment focused on achieving team goals.
• Maintained a high level of accuracy by conducting thorough reviews of enrollment applications, ensuring compliance with CMS regulations.
• Promoted to Enrollment Representative 4 due to extensive skills and knowledge within Medicare Enrollment and assigned to train and mentor new team members and provide quality assurance within CPU.
• Routinely assigned highly escalated issues received from business partners, complaints to Medicare and escalated complaints within Humana as well as Urgent Inquiry, Executive Inquiry, Grievance and Appeals and issues escalated directly to Bruce Broussard.

• Contributed to a positive work environment by fostering teamwork and collaboration among colleagues.
• Facilitated Medicare enrollment processes, ensuring compliance with regulatory requirements and timelines.
• Processed enrollment applications efficiently, ensuring accuracy and timely completion of tasks.
• Developed a deep understanding of various Medicare plans and regulations to provide expert advice to clients in need of guidance.
• Served as a mentor for new hires in the department, sharing best practices for successful Medicare claims processing techniques.
• Extensive knowledge and experience with applications such as CI, AE, MARx, RxNova, Argus, Ebilling, MedHok and CCP/GCP.
• Exceeded production and qualify goals regularly.
• Received, reviewed and verified new enrollment applications and ensured information was recorded accurately and timely.
• Daily processing of TRR replies, UI replies, CMS replies including CMS rejections which required in depth research and resolution.

• Operated package sorting equipment to ensure efficient processing of shipments.
• Collaborated with team members to optimize workflow and meet delivery deadlines.
• Maintained safety protocols while handling hazardous materials and operating machinery.
• Conducted quality checks on packages to verify accuracy and prevent errors.
• Proved successful working within tight deadlines and a fast-paced environment.
• Used hand-held scanners and physical logs to accurately track item movements.
• Verified correct labels and accurate shipping information on packages to avoid shipping to wrong addresses.
• Exceeded performance expectations during peak seasons, managing high volumes of shipments without compromising on quality or timeliness.
• Removed jams and unblocked conveyor system to maintain flow of goods.
• Contributed to increased productivity by working effectively in high-pressure situations.