medicare compliance officer resume example with 20+ years of experience
Jessica
Claire
resumesample@example.com
(555) 432-1000,
Montgomery Street, San Francisco, CA94105
:
Summary
Highly motivated Sales Associate with extensive customer service and sales experience. Outgoing sales professional with track record of driving increased sales, improving buying experience and elevating company profile with target market.
Highlights
Guest services
Inventory control procedures
Merchandising expertise
Loss prevention
Cash register operations
Product promotions
Education
Central Michigan University, Expected in May 1999 ā āMaster of Science:Administration Health Services - GPA:
The University of Toledo, Expected in ā āBachelor of Business Administration: - GPA:
, Expected in June 1991 ā āSpecializing:Management - GPA:
Experience
Mercy Health - Medicare Compliance Officer Warren, OH, 01/2007 - Current
Responsible for development, implementation and administration of a Medicare compliance program to support the operation of Medicare plans affiliated with CareSource Management Group (CSMG) and its family of companies.
Act as a liaison between CSMG and the Center for Medicare and Medicaid Services (CMS) or its designees.
Analyze new regulatory requirements for organizational impact and implementation.
Advise management on internal polices as they relate to external regulatory environment and provide routine new staff orientation on regulatory compliance.
- Director , , 09/2005 - 01/2007
Responsible for providing leadership and direction to regional Provider Relations and Database Management staff to support provider network development and database management.
Supported provider network while providing excellent service to both internal and external customers.
Maintained regional compliance with regulatory requirements through database management and coordination of recruiting efforts.
- Manager of Provider Relations , , 07/2003 - 09/2005
Responsible for effective management of the day to day operations of the PR Department to include the external PR Representatives (Central and Southwest regions) and the internal Database Management staff.
Oversee accuracy and integrity of provider data, including credentialing, fulfillment and physician network development.
Coordinated the appropriate system support and enhancements needed for management of the PR unit in conjunction with the Information Technology Department.
Ensured network compliance with all regulatory requirements as well as with all company-mandated polices and procedures specific to URAC, HEDIS or other business functions.
Common Spirit - Manager Tucker, GA, 01/2002 - 07/2003
Government Programs & Professional Relations - Organizing, directing and ensuring the corporate compliance regarding the Plan's Provider Agreement with the Ohio Department of Job & Family Services (ODJFS) and applicable sections of the Ohio Administrative Code (OAC) and Ohio Revised Code (ORC).
Oversee credentialing staff responsible for directly contracted Family Health Plan, Inc.
physicians, practitioners and other providers.
Manage staff responsible for maintaining and printing the Family Health Plan, Inc.
network provider/physician directory.
Manage staff responsible for new physician/provider orientations, physician contract/appeal issues and overall physician/provider relations.
Represent the company at the state level regarding regulatory and legislative issues Prepared for National Committee on Quality Assurance (NCQA) review and maintained processes to support accreditation.
- Manager of Government Programs , , 06/1999 - 01/2002
Organized, directed and ensured the compliance of all Family Health Plan, Inc., Family Health Plan of Michigan and Genesis Health Plan of Ohio Inc.'s managed care programs with multiple federal and state regulatory bodies.
Provided regulatory supervision and oversight to staff in terms of interpretation relative to regulatory requirements and the consequences of not meeting the requirements.
Assisted in the development and implementation of new products, services, policies, and administrative agreements.
Managed all filings of materials to the Health Care Financing Administration, Ohio Department of Job & Family Services, Ohio Department of Insurance and the Michigan Insurance Bureau.
Monitored updates or revisions to insurance regulations, codes and statues and incorporated into Family Health Plan, Inc.
business practices.
Represented company at the state and federal levels regarding regulatory and legislative issues.
- Program Coordinator , , 03/1997 - 06/1999
Interacted with Health Care Financing Administration (HCFA) officials regarding corporate compliance with laws and regulations.
Submitted member and marketing materials to HCFA for review and approval.
Prepared for Family Health Plan, Inc.'s HCFA site review.
Provided weekly presentations to providers and prospective members in the community regarding Family Health Plan Inc.'s Medicare risk product.
Trained Sales staff regarding HCFA compliance and all other relevant issues.
Created and updated all departmental policies and procedures.
Created and implemented a New Member Orientation program for Family Health Plan's Medicare risk product.
Provided outreach to senior organizations in the community and attended community sponsored events.
- Network Development & Contracting Team Coordinat , , 09/1996 - 03/1997
Identified and visited targeted provider offices in various markets to develop relationships, negotiate contracts and educate providers about Family Health Plan.
Manage the activities of two (2) team representatives.
- Government Programs Supervisor , , 03/1996 - 09/1996
Monitored and reported legislation that impacts Health Maintenance Organizations (HMO) and the health insurance industry.
Interacted with state and federal governmental representatives regarding regulatory compliance issues.
Assisted in a service area expansion of our existing Medicare risk product into Lima, Ohio (Allen County).
Coordinated and promoted generation of individual and group Medicare risk product (SeniorSense ) sales.
- Public Business Liaison , , 04/1995 - 01/1996
Performed Medicare risk product individual enrollments.
Assisted in Medicare/Medicaid enrollment projections and promotion of Family Health Plan, Inc.
product to providers, public and government agencies.
Assisted in the development of Medicare group sales activities.
Drafted policies and procedures.
- Member Services Representative , , 03/1993 - 04/1995
Coordinated Medicare risk program and presentations, counseled members on benefits, drafted policies and procedures, performed special projects for Member Services Department Manager, performed data entry.
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