Tessa Hayes
Passionate and dedicated Risk Management Professional with over a decade expertise within Medicaid Risk and Medicare Enrollment at Humana, excelling in regulatory compliance reporting, root cause analysis, issue resolution, and proactive risk assessment. Recognized for implementing process improvements that enhanced operational efficiency. Skilled in advanced Excel and clear interpersonal communication, driving informed decision-making and fostering cross-functional teamwork to resolve complex Medicare and Medicaid Enrollment operational issues and risk assessment .
Work History
Risk Management Professional 2
3 Years 8 Months- Proficiently oversee compliance metrics for end of month reporting to ensure adherence to regulations and internal policies as they pertain to Medicaid state based contract guidelines and state and federal requirements while performing daily in-depth risk assessment and root cause analysis for multiple lines of business throughout Medicaid.
- Consistently met time sensitive deadlines for completing critical tasks such as regulatory reports and presentations to address identified risks and implemented process improvements that enhanced operational efficiency and accuracy.
- Participated in weekly and monthly meetings to provide findings of ongoing trends and opportunities to operational partners and end to end process meetings for future Medicaid plans.
- Managed multiple projects simultaneously while maintaining strict deadlines and high-quality work standards including training guides, risk assessments and Medicaid Letter and Metric guide.
- Assisted in developing comprehensive training materials for compliance metrics and customized risk and compliance training programs.
- Strengthened current team risk and compliance review documentation, validated compliance metrics logic with data team and tracked process updates with operations to uncover trends, patterns and gaps in process.
- Efficiently developed and implemented corrective action plans (CAP) for non-compliance issues and presented to senior management and business partners.
- Showcased strength in ability to work independently and use knowledge-based judgement and attention to detail to prepare compliance metrics reporting, utilizing in-depth experience in Microsoft Excel and SharePoint, resulting in accurate information being presented to upper leadership.
- Analyzed complex data sets within Power BI and SQL Server Reporting Services to identify trends and patterns within operations, data logic, state eligibility and enrollment policies and procedures, driving informed decision making.
- Accrued extensive knowledge and experience in Medicaid Contract compliance requirements for multiple state-based plans such as Behavioral Health, Dual Demo and Medicaid Dual Eligible Special Needs.
Enrollment Representative 4
2 Years 4 Months- Conducted in-depth assessments of CMS cases and provided thorough root cause analysis of highly escalated and complex Medicare Enrollment issues accurately and timely, involving Medicare Dual Eligible SNP and Auto Assign, Group and Individual Medicare Enrollment, New Enrollment, CTM, member inquiries, and Grievance and Appeals.
- Selected by leadership to join the Special Operations Team within RSO Enrollment due to the ability to resolve escalated Medicare Enrollment issues accurately and timely, using extensive knowledge and experience of CMS guidelines and procedures.
- Mentored junior team members, fostering a collaborative environment focused on professional development.
- Consistency trusted to use independent decision making, often needing to think outside of established processes, to resolve highly escalated issues related to Medicare Enrollment and assigned special projects and tasks by management.
- Built 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, Group Medicare Enrollment.
Enrollment Representative 2
8 Years- Researched root cause and resolved CTMs, Inquiries and Rejection TRR and UI replies received from CMS in a timely manner exceeding standards for compliance timeframes and quality with an average of 40 cases reviewed daily.
- Analyzed and reported trends, issues, and concerns for further assistance in order to prevent recurrences of the issues for other members.
- Connected meaningfully with members to build emotional engagement and member advocacy.
- Simplified complex issues and integrated internal efforts to deliver an optimal member experience.
- Employed knowledge of CMS chapter guidelines to resourcefully resolve escalated access to care issues in a timely manner, often needing to think outside of established processes to provide enrollment needs and eligibility verification for our members.
- Participated in ongoing education and training sessions to remain updated on changes in Medicare regulations and policies.
- Maintained a high level of accuracy by conducting thorough reviews of enrollment applications, ensuring compliance with CMS regulations.
Education
High School Diploma
Skills
Timeline
Risk Management Professional 2
Enrollment Representative 4
Enrollment Representative 2
North Bullitt High School
2018 Shining Star Award
Received Shining Star Award by leadership for excellent service and exemplary attention to detail and dedication for member care.
Applause Award, 2025
"Committed - Members first mentality at work" Awarded by management in October, 2025 for exemplary attention to detail and dedication to our members by identifying and carefully documented errors, demonstrating initiative and professionalism, and communicating identified issues with thorough documentation and professionalism, ensuring the concerns were fully addressed.
Applause Award, 2026
"Committed - Caring for our members" Awarded by management in July, 2026 for dedication to resolving complex, urgent access to care issues for our members and consistent commitment to member friendliness.
"Committed - Appreciation for passionate cross team collaboration" - Awarded by management in March, 2026 for working with partnering team to ease high work inventory and engage in learning the process and finding more efficient ways to complete assigned duties.