Compliance and result oriented business leader with more than ten years in the HealthCare industry with diverse experience in compliance, quality, operations and management. Applies strong analytical and critical thinking skill to employ creativity and innovation to overcome challenging and complex issues across operations, processes, employees, and cost.
Skills
SME Medicare Regulations and NYS MLTC Enrollment
Regulatory Compliance
Multi-Site Operations
Business operations
Strategic Planning
Data collection and analysis
Risk analysis and management
Trouble shooting and problem resolution
Process improvement
System Implementation
Staff and Team management
Team building
Verbal and written communication
MS Office
Work History
Enrollment Operations Manager, 08/2018 - Current University Of Colorado – Aurora, CO,
Oversee the overall Enrollment operations for Medicare, Dual and Manage Long Term Care lines of business.
Strengthened performance metrics tracking and analysis to enhance tactical and strategic company plans.
Manage the day-to-day inventory and long term strategic activities within the department.
Established efficient workflow processes, monitored daily productivity and implement modifications to improve overall compliance, quality and effectiveness.
Increased compliance rating with Medicare regulation by developing and implements an end-to-end enrollment Quality Auditing program.
Collaborated with all operational departments to identify and recommend changes to existing process to improve compliance, accuracy and efficiency.
Collaborated with IT to develop automation to maxims efficiency and reduce labor cost.
Built and maintain a strong professional relationship with NY state local LDSS offices and their enrollment vendor Maximus.
Decision maker for Enrollment during the Medicare Annual Enrollment Redness workgroup.
Collaborated with Finance and IT to restructure Medicare and Dual billing structure and invoice layout.
Continuously mentor, coach and trained two supervisors and three quality auditors.
Organize all departmental employee engagement activities and events.
Complaince Internal Audit, 07/2017 - 08/2018 Fidelis Care – City, STATE,
Responsible for conducting various Medicare and New York State Medicaid audits to ensure compliance with all federal and state laws and regulations.
Draft audit reports provided to executives on results and at risk areas.
Form crucial relationships across business units to create unity in order to leverage a compliance culture.
Serve as subject matter expert and compliance support to Utilization Management, Claims, Appeals and Grievances, Pharmacy and Enrollment operations throughout recent CMS audit.
Develop remediation plans for several business areas post CMS audit to ensure processes are corrected and compliant.
Reviewed and approved audit universe pre CMS submission.
Conduct Model Audit Rule reviews within each department to ensure Fidelis is following all applicable financial reporting regulations.
Conduct internal marketing fraud investigations.
Supervisor, Business Info Management & Anallysis, 12/2014 - 03/2017 Coventry Health Care – City, STATE,
Managed a team of twelve multi-site quality auditors on various Medicare Compliance End to End focused audits that included; Medicare Part C and D Appeals and Grievances, Complaints Tracking Module, Vendor Call Quality, Low Income Subsidy process, Best Available Evidence, Enrollment, Late Enrollment Penalty and correspondent quality to drive process improvement and ensure compliance metrics are met.
Created Quality Program on identified company risks for Aetna Medicare Appeals, Grievance, Inquiry Calls, and Health Insurance Exchange Complaints.
Captured CMS Guidance and Audit Protocols to provide data to each business owner identifying errors and assisting in process improvement.
Organized and lead meetings with business owners and Compliance leads to discuss error trends and focus on ways to improve and calibrate on audited areas.
Managed additional projects as needed by the business when risk are determined.
Quality Auditor and Sr. Quality Auditor , 01/2010 - 12/2014 Coventry Health Care – City, STATE,
Conducted various Medicare Compliance End to End focused audits that included but not limited to; Late Enrollment Penalty, Medicare Part C and Part D A&G, Enrollment, and Low Income Subsidy to ensure the various departments are following CMS and Compliance guidance.
Supported the Medicare Part C and D Grievance teams with the development of their staff while playing an essential role in achieving the Customer Service Operations phone quality metrics for performance standards and calls monitoring.
Provide feedback on all audits via face-to-face, conference calls and written reports. • Review and conducted second level appeals from the different business areas on audits preformed.
Provide coaching and mentoring to auditor as needed when error assigned are invalid.
Conducted Peer-to-Peer reviews monthly to support calibration across the quality team.
Acted as a support/resource to the CSO in the transition to new program updates.
Developed and maintained positive relationships with all levels of customers both inside and out of the operations.
Provided insight on reported statistics to help improve overall CSO phone quality results.
Education
High School Diploma: , Expected in - Earl Warren - San Antonio, TX, GPA:
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