Over 24 years of work experience with increasing levels of responsibility. Driven and compassionate Fraud Control and Privacy & Security Officer, capable of handling a wide range of compliance functions. Oversight of three distinct programs, Privacy & Security, Fraud, Waste & Abuse and Compliance Training program. Extensive experience investigating allegations of wrongdoing and privacy and security breaches, including implementing (or overseeing the implementation of) corrective actions to resolve substantiated findings. Expert in coordinating, implementing and managing training and educating the workforce on compliance related matters to include fraud, waste and abuse detection and prevention and privacy and security awareness and obligations.
Implements region-wide privacy and security compliance initiatives to ensure the execution of corporate compliance directives in the region
Develops, maintains, and directs the region’s Privacy and Security Compliance program, to include development of applicable policies and procedures, training, communication, auditing, and monitoring, and investigation of privacy and security complaints
Develops, recommends, and implements the region's Fraud, Waste and Abuse prevention initiatives, to include developing and initiating the annual FWA survey, to analysis of findings, reporting findings to senior management, and auditing for ongoing compliance with corrective action plans
Oversees or conducts – either as the lead investigator or in partnership with others – investigations into allegations of wrongdoing committed by vendors, employees, members, and providers; and, allegations of privacy and security issues
Oversees the annual compliance training programs for the health plan and specialty training for both the health plan and the medical group, to include overseeing training module launch implementation of instructor-led, web-based, and one-on-one instruction; developing status reports for delivery to senior management, and developing corrective action plans to address non-compliance
Manages and develops staff within the department. Coaches staff on individual development opportunities
Conducted independent or joint investigations of fraudulent or illegal activities to include recommending and overseeing installation of covert video surveillance and still photography equipment, reviewing captured documentation of subjects and maClaire recommendations on next steps to the Situation Management Team, local stakeholders and the National Special Investigative Unit
Reported substantiated fraud allegations to the National Association of Insurance Commissioners (NAIC)
Oversight of the investigations of claims fraud cases identified through National Fraud Control Office
Use supervisory skills to respond to and resolve member problems, concerns, and requests for information
Oversee and manage facility operations: to include housekeeping, security, maintenance, and crisis management
Provide supervision to staff to ensure policy and procedures are maintained
Partner with MCA to coordinate community outreach programs including school partnerships, open houses, volunteer program etc
Review and finalize facility proposals for community outreach programs
Serve as liaison between the call center, member services and other departments as appropriate
Deliver training and coaching to medical office employees, i.e. orientation, system implementation, product knowledge
Coordinate/assist the project manager with remodels moves, including communicating with other departments
Maintain monthly department budget reports
Facilitate team meetings
Ensure designated areas are in compliance with regulatory guidelines and is prepared for surveys and audits
Coordinate safety and emergency procedures per organizational and regulatory standards
Member of Healthcare Compliance Association - Certified Healthcare Privacy Compliance (CHPC)
Member of Association of Certified Fraud Examiners - Certified Fraud Examiner (CFE)
HIPAA
Investigations
Training Awareness
Leadership and collaboration
Analytical
Relationship building
Interpersonal
Oral and written communication
Time management
Ability to work and lead with little direction
Lead and direct others
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