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compliance quality manager resume example with 11+ years of experience

Jessica Claire
  • , , 609 Johnson Ave., 49204, Tulsa, OK 100 Montgomery St. 10th Floor
  • Home: (555) 432-1000
  • Cell:
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Professional Summary

Seasoned Healthcare Compliance professional with 10+ years of experience working collaboratively with Executives and staff to optimize adherence to policies, procedures, standards and regulations. Well-versed in comprehensive analysis of operations, process improvement recommendations, policy development, training management and reporting. Well-organized and systematic with excellent communication and planning abilities. Looking for challenging position in fast-paced environment.

Detail-driven Compliance professional focused on maximizing company compliance with applicable laws and standards. Knowledgeable about internal controls, process evaluations and procedural reviews.

Highly skilled in managing and leading health care compliance integrity programs and measuring organizational compliance effectiveness to prevent, detect and correct non-compliance and identify potential fraud, waste and abuse.

Expertise in accreditation for NCQA, and URAC requirements. Experience in pharmacy benefit management programs including, Medicare Advantage, Medicare-Medicaid Plan (MMP) and Dual Eligible Special Needs Plans (D-SNPs). Quality Improvement, CMS STARs Ratings, and HEDIS requirements. Experience in Provider Credentialing, CMS audits reviews and regulations including, OIG audits, managed care regulations, participating in provider contract agreements, HIPAA privacy, and Third-Party Administration (TPA) laws.

Familiarity with operational, financial, and HR procedures and regulations. Proficient in Microsoft Word, Excel, and PowerPoint.

Skills
  • Detail-oriented
  • Federal and state regulations
  • Policy analysis
  • Auditing experience
  • Process Management
  • Internal Audits/Quality controls
  • Conducting investigations/Risk analysis
  • EMR / EHR
  • Statutory Reporting
  • Training & Development/Training Procedure Implementation
  • Analytical skills
  • Collaboration
Work History
Compliance & Quality Manager, 08/2019 to Current
CuraleafAmargosa Valley, NV,
  • Oncology Analytics provides health plans, providers and patients with a data driven utilization management solution that delivers real-world, evidence based analytics focused exclusively for oncology.
  • Oncology Analytics e-Prior Authorization platform covers the full spectrum of therapeutics across all cancer types and stages, including chemotherapy, radiation therapy, and supportive care.
  • Responsible for the compliance department functions including, quality management and quality improvement support.
  • Responsible for reviewing, managing and evaluating compliance issues/concerns for the company ensuring that the company is accredited and complying with HIPAA, URAC, NCQA, state and federal law and regulatory requirements.
  • Monitor the performance of the compliance program and related activities on a continuing basis, taking appropriate steps to improve its effectiveness.
  • Responsible for providing reports on a regular basis, and, as directed or requested, keep the Corporate Counsel/Chief Compliance and senior management informed of the operation and progress of compliance efforts.
  • Consults with corporate counsel as needed to resolve difficult legal compliance issues.
  • Responds to alleged violations of rules, regulations, policies, procedures, and standards of conduct by evaluating and recommending the initiation of investigative procedures.
  • Work with Human Resources and others as appropriate departments to develop an effective compliance training programs, including introductory training for new employees and ongoing training for all employees and managers.
  • Develops and oversee a system for uniform handling of alleged violations.
  • Ensure compliant systems and processes are in place for effective management of Plan functions, including but not limited to: enrollment, billing, marketing, member services, claims processing, grievances and appeals, medical management, quality management, reporting, network management, pharmacy management, contract administration, and other CMS requirements.
  • Facilitate and maintain an effective compliance communication program for the organization, including promoting use of the compliance hotline, awareness of standards of conduct, and understanding of new and existing compliance issues and related policies and procedures.
  • Identify potential areas of compliance vulnerability and risk, develop and implement corrective action plans for resolution of problematic issues, and provide general guidance.
  • Oversee internal audit controls to ensure departmental compliance to all regulatory standards.
  • Corporate Compliance/Privacy – MCNA Dental Plans Fort Lauderdale, FL.
  • Managed effective action plans to respond to audit discoveries and compliance violations.
  • Liaised with risk management, internal audit and employee services departments to direct compliance issues to appropriate channels for investigation and resolution.
Corporate Compliance/Privacy , 07/2015 to 08/2019
Microsoft CorporationAtlanta, GA,
  • MCNA Dental is a leading dental benefits manager committed to providing high quality services to states agencies and managed care organizations for the Medicaid, Children’s Health Insurance Program (CHIP), and Medicare members.
  • Responsible for the compliance department functions monitoring and auditing activities for all state and federal regulatory compliance, and Medicaid & CHIP contract compliance.
  • Responsible for developing and delivering a comprehensive compliance and training education program.
  • Responsible for documenting the auditing and monitoring results, preparing audit reports, and summaries for the Compliance Committee.
  • Attend the Quality Improvement Committee & Credentialing Committee.
  • Responsible for monthly, quarterly, annual reports, and ensure timely submission to HHSC.
  • Conduct compliance audits, develop and implement corrective action plans.
  • Participate in URAC, NCQA accreditation surveys.
  • Responsible for audit team response for Medicare & Medicaid Audits.
  • Responsible for implementing various compliance programs, including Fraud Waste and Abuse (FWA) and HIPAA.
  • Responsible for collaborative partnerships with key members of management to evaluate and address compliance issues on an ongoing basis and develops and leads completion of annual work plans.
  • Responsible for submission of consumer and provider communication materials, including participation in their review and timely submission to HHSC.
  • Responsible for implementing and maintaining policies and procedures to comply with state law, federal law, contract requirements, and various standards.
  • Responsible for maintaining and track laws and regulations, contract documentations, and amendments.
  • Assist leadership in designing and improving processes to ensure compliance with statutes, regulations, and guidelines.
  • Assist in develops and implements privacy policies and procedures as outlined in 45 CFR 164, and receives complaints.
  • Assist with planning and implementation of response to privacy breaches and regulatory response.
  • Assists with the investigation of compliance violations received through the compliance hotline and email.
  • Conduct investigation of privacy incidents and ensure timely reporting to HHSC.
Regulatory Compliance Manager, 10/2009 to 07/2015
Catamaran RxCity, STATE,
  • CatamaranRx is an innovative pharmacy benefit management business managing the prescription drug benefits of commercial, Medicare, Medicaid and other governmental health plans.
  • Responsible for the compliance department functions monitoring and auditing activities-based Company’s Medicare Advantage enrollment and claims processes.
  • Directs the analysis and development of Medicare related reports to support functional areas such as Utilization Management and Pharmacy.
  • Ensured that all service levels are met for all functional areas supporting the plan, including corporate, regional, and local functions.
  • Addressed the need for corrective action when any service levels are not met.
  • Responsible in established standards, policies and procedures that are compliant with CMS requirements and regulations.
  • Scheduled and conducted audits of departments according to CMS standards and company policies and procedures.
  • Responsible for drafting a quarterly compliance audit and presenting the results to management.
  • Worked directly with departmental managers to make sure that all personnel issues were in line with company and governmental policies.
  • Managed development and maintenance of materials for audit and tracking of audits.
  • Responsible for planning, coordinating and executing control, operational and compliance reviews.
  • Identified areas of risk, evaluating compliance with applicable regulations and policies, and making recommendations to enhance the overall control environment.
  • Prepared written reports for each audit conducted for senior management.
  • Assisted in the development of policies & procedures, and other operational changes.
  • Responsible for creating and implement member/provider compliance tracking, trending, and reporting tools.
  • Supported management staff with internal and external audit preparation.
  • Interacts with all departments, management, and employees regarding compliance issues.
  • Corporate Compliance Manager and Privacy – I can Benefit Group.
  • Prepared and presented comprehensive reports to upper management and audit team, covering issues and recommendations.
Education
Master of Health Science: , Expected in 12/2017 to Nova Southeastern University - Davie, FL
GPA:
Bachelor of Science: Health Care Administration, Expected in 05/2013 to Ashford University - San Diego, CA
GPA:
Affiliations
Health Care Compliance (CHC), Health Care Risk Management (CPHRM), and Professional in Patient Safety (CPPS)
Certifications

Certified HealthCare Compliance (CHC)

HealthCare Risk Management (CPHRM)

Patient Safety (CPPS)

,

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Resume Overview

School Attended

  • Nova Southeastern University
  • Ashford University

Job Titles Held:

  • Compliance & Quality Manager
  • Corporate Compliance/Privacy
  • Regulatory Compliance Manager

Degrees

  • Master of Health Science
  • Bachelor of Science

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