AVERY CROPPER-MAKIDI
Philadelphia
Summary
Detail-oriented quality assurance professional with extensive experience in appeals processing and risk assessment within the healthcare and pharmaceutical sectors. Demonstrates strong analytical skills and adaptability, successfully ensuring compliance with CMS guidelines while optimizing operational efficiency. Proven track record of enhancing process workflows and fostering collaborative team environments.
Overview
10
10
years of professional experience
Work History
Quality Review Analyst, Medicare Part C Appeals
Aetna, CVS Health
12.2022 - Current
- Conducting internal audits and inspections to evaluate the effectiveness of Quality Assurance processes.
- Participating in and leading meetings on new standards, trends, and regulations affecting the appeals process.
- Providing administrative support by preparing reports, analyzing trends, and assisting management with documentation needs.
- Maintaining up-to-date knowledge of applicable laws, CMS guidelines, policies, and procedures related to appeals processing.
- Demonstrating the ability to work independently, as well as collaboratively, within a team environment.
- Providing feedback and coaching, when necessary, while performing quality assurance reviews.
Lead Coordinator, Complaint and Appeals
Aetna, CVS Health
10.2019 - 12.2022
- Identified and researched all enrollee and provider appeals components, complaints, and grievances for Medicare Part B, Part C, and Part D plans.
- Provided support on the weekends as a Team Lead, which included assisting other coordinators, and working in various queues while managing a caseload.
- Worked as a Dual Eligible Special Needs Plans (DSNP) specialist to ensure that appeals submitted by or on behalf of the enrollees meet Medicare, Medicaid, and CMS guidelines.
- Identified potential risks and cost implications to avoid inaccurate responses and/or decisions that may result in additional rework, confusion to the constituents, or legal ramifications.
- Served as a liaison between patients, healthcare providers, and insurance entities to resolve disputes.
- Collaborated with Aetna's clinical team and external vendors to ensure timely resolution of appeals.
- Provided guidance and mentoring to new members of the team.
Pharmacy Technician
CVS Pharmacy
Paoli, PA
03.2016 - 02.2019
- Performed administrative duties such as data entry, inventory management, and record-keeping.
- Ensured all medication needs and regulatory compliance standards were met for our patients, demonstrated ethical conduct, and maintained patient confidentiality.
- Managed all assigned pharmacy workstations and tasks to support the team's ability to promptly, safely, and accurately fill patient prescriptions.
- Maintained a daily inventory of pharmaceuticals, and ensured proper storage conditions.
- Provided customer service support by handling patient inquiries and coordinating with healthcare professionals.
Education
Master of Science - Information Technology, Cybersecurity
Capella University
Minneapolis, MN12-2025
B.S. Business Management - College of Business and Public Management, AACSB
West Chester University
West Chester, PA12.2018
Skills
- Patient Registration & Admissions
- Medical Terminology & CMS Guidelines
- Insurance Verification & Billing
- Customer Service & Call Center Expertise
- Electronic Health Records (EHR)
- Microsoft Office Suite & Data Entry
- HIPAA Compliance & Risk Assessment
- Record Keeping & Documentation
- Team Leadership & Training
Timeline
Quality Review Analyst, Medicare Part C Appeals
Aetna, CVS Health
12.2022 - Current
Lead Coordinator, Complaint and Appeals
Aetna, CVS Health
10.2019 - 12.2022
Pharmacy Technician
CVS Pharmacy
03.2016 - 02.2019
Master of Science - Information Technology, Cybersecurity
Capella University
B.S. Business Management - College of Business and Public Management, AACSB
West Chester University