Angela Sykes
Washington
Summary
Dynamic professional with extensive experience at AETNA in grievance and appeals operations. Proven ability in conflict resolution and regulatory compliance, successfully enhancing team performance and efficiency. Skilled in data analysis and patient advocacy, I effectively coach and mentor staff to achieve high-quality outcomes in managed care environments.
Overview
3
3
years of professional experience
Work History
Sr Coordinator Grievance & Appeals Ops
AETNA
Pittsburgh
03.2024 - Current
- Conducts team reviews, interpretations, and appeals filed by patients, escalating more complex issues and concerns to management for review and follow-up.
- Ensure adherence to regulatory requirements, conduct internal audits, and address any identified compliance issues with the Complaint and Appeals policies and procedures.
- Facilitates in-depth reviews of decisions and case files to determine whether there are errors or anomalies in the application of law or evidence.
- Oversees the drafting and progression of appeal decision letters, conducting detailed follow-up for timely and thorough follow-up and resolution.
- Monitors key performance indicators (KPIs) and metrics to evaluate the effectiveness and efficiency of the appeals and grievance process.
- Facilitates and provides educational materials, training programs, and presentations to enhance understanding of the appeals and grievance process.
- Coaches and mentors other colleagues in techniques, processes, and responsibilities for effectively handling member complaints and appeals.
- Train junior-level staff to promote the development of departmental capabilities.
Patient Service Representative
UPMC
Pittsburgh
01.2024 - 08.2024
- Initiated patients for appointments with timely benefits verification, referral processing, and insurance authorizations.
- Escalated complex situations or complaints to management for resolution, as appropriate.
- Maintained patient confidentiality by adhering to HIPAA guidelines during all interactions.
- Oversaw compliance with hospital policies regarding patient registration and data entry accuracy.
Supervisor of Provider Data
OPTUM
Pittsburgh
02.2023 - 11.2023
- Effectively Increased teams Q1 index score from 2.61% to Q4 score 5% delivering high quality results
- Evaluated staff performance, communicating feedback, and setting personal goals by using motivational leadership style
- Tracked employee performance to determine areas of strength and improvement
- Delegating tasks to ensure efficiency and accuracy
- Led teams through onboarding process for swift integration into daily operations
- Communicated with cross-functional departments to maximize productivity and performance
Supervisor of Clinical Advocacy & Support
OPTUM
Pittsburgh
07.2022 - 01.2023
- Tracked employee performance to determine areas of strength and improvement by delivering high quality training
- Trained new employees on company policies, procedures, and software systems
- Ensured proper inventory levels were maintained through accurate ordering of supplies as needed
- Executed daily opening and closing procedures to company standard
- Communicating team priorities by leading meetings and giving presentations
Education
Bachelor of Arts (B.A.) - Economics
University of Pittsburgh
Pittsburgh, PASkills
- Multidisciplinary team collaboration
- Medicare/Medicaid Regulatory Compliance
- Conflict resolution
- Patient advocacy
- Administrator, Staff, Supervision
- Strong Computer Skills
- Data analysis and modeling
- Appeals processing
- Medical records
- Managed care
Timeline
Sr Coordinator Grievance & Appeals Ops
AETNA
03.2024 - Current
Patient Service Representative
UPMC
01.2024 - 08.2024
Supervisor of Provider Data
OPTUM
02.2023 - 11.2023
Supervisor of Clinical Advocacy & Support
OPTUM
07.2022 - 01.2023
Bachelor of Arts (B.A.) - Economics
University of Pittsburgh
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