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Medicare Compliance Analyst Resume Example

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MEDICARE COMPLIANCE ANALYST
Summary
A challenging and responsible position where my experience, education, and training will be effectively utilized in the realization of corporate goals while promoting personal and professional growth.
Experience
TMG HealthJessup, PAMedicare Compliance Analyst12/2015 to Current
  • actively interface with all management, departments and clients to help ensure compliance with regulatory and contractual requirements.
  • Support the execution of the company's Compliance Plan
  • Investigate potential compliance issues and facilitate the development of a Process Improvement Plan (PIP) or Corrective Action Plan (CAP)
  • review, and interpret regulations for both state and federal government health programs and client contractual requirements
  • Assess the need for, develop and update Policies and Procedures
  • Facilitate and coordinate regulatory audits
  • The development, implementation and execution of risk assessments and internal monitoring programs
  • The investigation and reporting of potential Fraud, Waste and Abuse (FWA), privacy issues and HIPAA disclosure incidents
  • Coordinate the timely completion of regulatory reporting requirements
  • The receipt, review, tracking, dissemination and interpretation of CMS and other regulatory guidance related to Medicare and MMP Plans to determine impacts to the organization
  • participate on operational teams to provide guidance interpretation;
  • Facilitating the development of Process Improvement Plan (PIPs) and client and CMS requested Corrective Action Plans (CAPs) for clients
  • ensure that corrective actions were effective in remediating the issue
  • Coordinate the investigation and develop initial and quarterly reporting of potential Medicare & Medicaid fraud, waste and abuse (FWA) issues to clients
  • Coordinate with Operational Teams to facilitate the development of CMS Part C and D Reporting requirements
  • Developing required internal reporting 
TMG HealthJessup, PAOperations Compliance Specialist11/2014 to 12/2015
  • supporting the monitoring, review and implementation of CMS and other regulatory requirements and changes
  • This included supporting the gathering and logging of data utilizing Facets, image viewer and other available systems to ensure that the Company and its employees cooperate and comply with any requests and/or demands made by CMS, HHS, OIG or other Federal or state government agency
  • ensuring all regulatory communications/updates are received, summarized, catalogued, disseminated across functional departments 
  • acting on matters related to non-compliance with policy or regulatory guidance and the documentation of mitigation and corrective actions, assisting with internal monitoring of CMS and other regulatory requirements using CMS reporting and internal monitoring results, supporting the company's efforts to detect Fraud, Waste and Abuse and meet all Privacy and Security requirements
  • development and implementation of the company's compliance plan and related compliance policies and procedures.
TMG HealthJessup, PAQuality Assurance Specialist05/2012 to 10/2014
  • My quality assurance duties included ensuring levels of testing met statistical significant standards on a monthly basis for clients and quarterly basis for processes, tracking and logging results in order to generate reports specific to clients, processor, and processes.
  • In addition I was responsible for notification immediately upon detection of any error and track all errors until verification of resolution.
  • I worked with business analysts to ensure correction programs were being implemented properly, and associated training was triggered and completed.
  • I also worked closely with Regulatory Compliance, Enrollment, Billing, and Reconciliation divisions to ensure the listed policies and procedures being used in the QA department were valid and up to date.
Scranton Urgent CareScranton, PAMA/Phlebotomist12/2010 to 06/2011
  • I performed a multitude of clerical duties including patient chart maintenance, insurance information processing, intake and discharge of patients.
  • I was also responsible for many clinical aspects of patient care such as the triage of patients, recording all vital signs, updating patient charts, EKG administration, Phlebotomy, IV set up, urinalysis, and any other laboratory testing required.
TMG HealthDunmore, PAEnrollment/TRR Processor03/2009 to 06/2012
TMG Health Remote LocationAt Home Claims Processor08/2006 to 03/2009
TMG HealthDunmore, PACustomer Service Representative04/2005 to 08/2006
AFL-CIODunmore, PACall Center Supervisor09/1998 to 12/1998
  • training of all phone bank volunteers; providing assistance as needed.
  • Analysis of all data obtained during outreach
United Steelworkers of AmericaPittsburgh, PAPolitical Campaign Intern07/1998 to 09/1998
  • I completed a phone canvass for a congressional race in Allentown, PA.
  • My responsibilities also included local canvassing by contacting individuals at their homes and compiling this data and reporting results based on information obtained.
  • I also acted as a secret services agent for a political event that was given by the Vice President of the United States.
  • I also did similar work for a local congressional race.
Education
Phlebotomy2011Fortis, Scranton, PA, US
Psychology/Biology2003University of Scranton, Scranton, PA, US
High School Diploma1998Scranton Preparatory School, Scranton, PA, US
Skills
Regulatory Compliance, documentation, inventory control, laboratory testing, regulation interpretation, Excel, Outlook, Power Point, Microsoft Word, patient care, personnel, Phlebotomy, Policies and processes documentation, Process Improvement, quality assurance, reporting, Risk Assessment, statistical analysis
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Resume Overview

Companies Worked For:

  • TMG Health
  • Scranton Urgent Care
  • TMG Health Remote Location
  • AFL-CIO
  • United Steelworkers of America

School Attended

  • Fortis
  • University of Scranton
  • Scranton Preparatory School

Job Titles Held:

  • Medicare Compliance Analyst
  • Operations Compliance Specialist
  • Quality Assurance Specialist
  • MA/Phlebotomist
  • Enrollment/TRR Processor
  • At Home Claims Processor
  • Customer Service Representative
  • Call Center Supervisor
  • Political Campaign Intern

Degrees

  • Phlebotomy 2011
    Psychology/Biology 2003
    High School Diploma 1998

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