Experience

Health Plan Services

• 1 - 100 Employee

• Internal Auditor

  • Oct 2018 - Present

  Conducts pre-delegation and annual audits for new and existing delegated entities to ensure compliance with the delegation agreement and regulatory requirements. Prepare audit reports and work papers, communications with team members, assist with audit interviews/ conferences, assist in quarterly audit update, ensure accuracy of work performed and maintain efficiency of operations. Work with internal departments to develop and maintain delegation agreements and assessment tools. Developing audit reports and corrective action plans when deficiencies are identified and documenting follow-up.



Optum

• Delegation Oversight

  • Nov 2017 - Mar 2018

  Conducted pre-delegation and annual audits for new and existing delegated entities to ensure compliance with the delegation agreement and regulatory requirements. Coordinated, conducted, and documented delegation assessments as necessary to be in Compliance with state, federal, NCQA, and any other applicable regulatory requirements. Developed audit reports and corrective action plans when deficiencies were identified, and documents follow-up to completion. • Presented audit results and documentation to Delegation Oversight Committee. Worked with internal departments to develop and maintain delegation agreements and assessment tools.



Ultimate Health Plans

• Delegation Oversight Auditor /Privacy Officer

  • Nov 2015 - Nov 2017

  Delegation Oversight Auditor for Credentialing, Claims, Member Services, Network, Nursing Line and Enrollment. Accurately developed, revised, and maintained all delegation audit tools and written agreements. Prepared all audit reports including correspondences and corrective action plans to ensure the provider satisfied all requirements within the allotted timeframe. • Audited Compliance Program which included review of Notices of Privacy practices, PHI, FDR Oversight monitoring, Standards of Conduct, HIPAA, Fraud, Waste and Abuse, Corrective Action Plans & Root Cause Analysis and Record retention. • Audited Disaster Recovery/Business Continuity plans for elements such as a clearly defined team, detailed plan, effective testing, crisis communications, employee safety, uninterrupted access & continuous IT OPS. • Maintained the Compliance hot-line and inbox, responding to any calls or emails immediately and conducting any necessary investigation. Ensured compliance with privacy practices and consistent application of sanctions for failure to comply with privacy policies for all company employees. Performed Compliance walkthroughs to ensure compliance with clean desk, printers, email and fax.



Integral Quality Care

• Senior Credentialing Analyst

  • Jun 2012 - Nov 2015

  Responsible for Managing transition of Credentialing from the Credentialing Verification Organization to an internal process to comply with AAAHC standards. Identifying and resolving gaps in transition of workload including those in reporting, Credentialing committee, Credentialing database. Reporting revisions to keep Credentialing desktops up to date. Credentialing of Healthcare and Facility providers for Florida Medicaid network.



WellCare Health Plans

• Delegation Oversight Auditor

  • Oct 2000 - Mar 2012

  AREAS OF EXPERTISE• Professional Relationship Building • Staff Leadership & Training • Business Operations • Quality Client Service • Research & Analysis • Policy Review &Implementation; Promoted to a Senior Specialist within this major managed care company to provide outstanding service related to credentialing and contract management. Effectively conduct audits for 65 delegated entities ensuring compliance with contractual agreements and regulatory requirements.Strategically prepare all audit reports including correspondences and corrective action plans to ensure the provider satisfies all requirements within the allotted timeframe.Conduct pre-delegation and annual audits for new and existing delegated entities ensuring that the provider continues to perform the delegated activities in accordance with the agreement and regulatory requirements.Accurately develop, revise, and maintain all delegation audit tools and written agreements.Conduct mock audits of department functions using State and accreditation audit tools. Develop corrective action plans to address any identified issues.Maintain all documentation to support evidence of compliance with all delegation requirements.Function as an expert in determining that the subject matter and policy requirements are in compliance with regulatory contracts.Efficiently create and present reports monthly to Delegation Oversight Committee.Key Accomplishments:Maintained an 85% overall minimum compliance score.Selected to Travel within Ohio, Indiana, Illinois, Missouri, New York, Connecticut and Hawaii to audit policies & procedures, and committee meeting minutes.



Blue Cross & Blue Shield

• Credentialing Coordinator

  • Oct 1998 - Oct 2000

  Presented monthly recommendations to a committee consisting of 6 physicians, to renew or discontinue individual provider or group participation.Generated monthly major account reports supplying updated pertinent data regarding an auxiliary network of 150 physicians. Participated as a member of the Grievance committee to represent the Department of Credentialing.Accurately maintained credentialing files in preparation of State and Federal compliance inspections.