Senior Business Process ConsultantCaci International Inc. – Sterling, VA,
Assists business case development for those proposed initiatives to which are assigned to ensure adequate assessment of opportunities, risks and return on investment.
Facilitates the optimization of business unit performance by enhancing alignment of policy, process and technology and designing/implementing for future business needs as well.
Leads large scale, cross-functional initiatives and programs that are intended to drive performance improvement, financial gains, customer satisfaction and improved compliance.
Provides policy guidance on assigned initiatives so that end-to-end processes are considered for maximizing effective implementation.
Measure vendor compliance with corrective action plans developed to improve performance.
Identifies improvement opportunities of the delegation and oversight process.
Organizes work teams, drives consensus and ensures end-to-end policy/process integrity to accomplish project work including: identification and confirmation of participants, establishment of a project plan, consistent work team engagement and productivity, meeting facilitation, consensus building, recommendation documentation and implementation oversight.
Performs detailed analysis of data, workflows, policies, and procedures, organization of staff, skills and offer potential solutions in order to execute initiatives.
Supports the project work by utilizing project management software such as, but not limited to, Excel, PowerPoint, Visio, and Microsoft Project.
Leads all levels of staff who are responsible for initiatives included in the company’s operating plan in order to support their success, development and effective completion and communication of their initiatives.
Assists other project leaders in specific areas as needed such as facilitation, analysis, process mapping, brain-storming, project management issues, etc.
Writes and delivers communication to all levels of organization to ensure support, awareness and effectiveness of process improvement initiatives.
Possesses and utilizes knowledge and experience leveraging IT solutions.
Participates in executive level meetings and presentations with both internal and external customers, specific to joint operation meetings.
09/2015 to 07/2018
Senior Compliance AnalystArch Capital Group Ltd. – Toronto, CA,
Respond to external requests for information required by the organization for its regulatory filings.
Manage compliance reporting responsibilities and respond to inquiries from federal regulatory agencies.
Perform analytical review of key metrics, issue write up management, and compliance projects or implementations.
Interpret and communicate federal requirements to internal and external clients.
Provide development guidance and assist in the identification, implementation, and maintenance of compliance policies, procedures and work instructions.
Assist in the identification, analysis, and resolution of compliance issues.
Research, review and provide interpretation of regulatory requirements as pertains to assigned business areas.
Assist in developing, producing and conducting compliance training programs.
Perform compliance audits, risk assessments and conducts related to ongoing compliance monitoring activities with assigned business areas, specializing in Medical Management and Quality Improvement.
Assist health plans in managing relationships with regulatory agencies and seek to resolve issues.
Assist management with interim health plan compliance officer responsibilities when needed.
Provides company-wide guidance on policies, contract issues and provisions, communications, workflow, and quality improvements initiatives.
07/2009 to 09/2015
Senior Case Management AssistantCentene Corporation – Midland, NC,
Participates in departmental and companywide evaluation, audit, improvement and compliance activities.
Organizes and leads work groups within the team to help identify at risk health groups and better target certain comorbidities for effective case management.
Analyzes department reports for efficiency of services, cost effectiveness and reports quality outcomes.
Perform audits and monitors the consistency and quality of departmental functions to comply with Health Nets standards, accreditation standards, federal, state and other regulatory requirements.
Performs detailed analysis of data, workflows, policies, and procedures, organization of staff, skills and offer potential solutions.
Asses if members meet criteria for authorization under Transition of Care based on DMHC, NCQA and Health Net National Policy guidelines.
Supports departmental work by utilizing project management software such as, Excel, PowerPoint, and Visio.
Identifies areas for process improvement and works with Management team to develop new processes and facilitates the implementation and training of new protocols.
Participates in job interviews and facilitates all training for new hires.
Create workflows, desktop procedures and power point presentations for training and actively participates in desktop committee meetings.
Present educational and data analyst findings to outside departments on all areas of case management.
Respond to queries from contracted provider, hospitals and other outside non-network providers.
10/2007 to 07/2009
Case Management AssistantSutter Health – San Mateo, CA,
Support case management/disease management review process by gathering and entering appropriate information for clinical review process.
Prepare documentation and present cases to nurse case managers or medical directors for review.
Triage process and prioritize nurse’s cases to meet regulatory turn-around times.
Expedite access to appropriate care for members with urgent or immediate needs.
Communicate with medical groups and providers on a daily basis to discuss specific member cases and needs.
Identify potential cases for case management, investigate possible care, process or compliance issues and notify the appropriate department/Case Manger with a plan of action to take.
Contact patients via phone and assess their current condition and help assist in access to care needs.
Education
Expected in to to
Associates Degree: Business Management / Healthcare Administration, Business Management University of Phoenix Woodland Hills - , CA GPA:
Expected in to to
Bachelor of Science Degree: Health Care Administration, Management - , GPA:
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