Experience

Devoted Health

• United States
• Hospitals and Health Care
• 700 & Above Employee

• Compliance Analyst

  • Jul 2022 - Present

  -Conducts both internal and external (FDR) audit and monitoring oversight activities for Medicare Advantage and SNP plans. -Manage and develop Corrective Action Plans and Audit Reports. -Develop and draft standard operating procedures, audit tools, policies, etc. -Provide support to the department in responding to business units regarding day-to-day operational compliance questions. -Draft and ensure audit reports are organized, accurate, and professional to convey reported issues… Show more -Conducts both internal and external (FDR) audit and monitoring oversight activities for Medicare Advantage and SNP plans. -Manage and develop Corrective Action Plans and Audit Reports. -Develop and draft standard operating procedures, audit tools, policies, etc. -Provide support to the department in responding to business units regarding day-to-day operational compliance questions. -Draft and ensure audit reports are organized, accurate, and professional to convey reported issues and audit findings. -Analyze and evaluate data, identify trends and risks, and make appropriate conclusions based on regulatory guidelines. -Collaborate with other departments for audits, corrective action, and compliance activities. Identifies and researches gaps in documentation, or potential areas of non-compliance, and suggests resolutions. -Assist in oversight of dashboard monitoring to ensure compliance. -Review HPMS memos and regulatory guidance for adherence to regulatory processes -Review and evaluate risk/ deficiency forms reported by various business areas Show less



Humana

• United States
• Insurance
• 700 & Above Employee

• Quality Audit Professional 2

  • Apr 2021 - Jul 2022

  Doral, Florida, United States -Auditing new hire/regular associate casework to maintain compliance with internal standards and Centers for Medicare and Medicaid Services guidelines. -Mentoring where development opportunities are found, and identifying further training opportunities. -Reviewing documentation and information in multiple systems to ensure quality of casework and mitigate risk in case of external audits. -Providing recommendations to improve training material, reference documents, and simplifying… Show more -Auditing new hire/regular associate casework to maintain compliance with internal standards and Centers for Medicare and Medicaid Services guidelines. -Mentoring where development opportunities are found, and identifying further training opportunities. -Reviewing documentation and information in multiple systems to ensure quality of casework and mitigate risk in case of external audits. -Providing recommendations to improve training material, reference documents, and simplifying older processes with simple solutions that alleviated friction points in interdepartmental work and serving as a subject matter expert.

• Grievance and Appeals Production Lead

  • Mar 2020 - Apr 2021

  -Analyzed casework and reports to identify and address friction points to improve outcomes for my direct reports through one-on-one mentorship and action plans. -Collaborated with and supported management and representatives to develop or improve processes, job-aids, and a training manual for the Appeals Team while simplifying ways to deliver and train those processes. -Reported, tracked, and often exceeded daily casework goals in a variety of case types including internal Presidential… Show more -Analyzed casework and reports to identify and address friction points to improve outcomes for my direct reports through one-on-one mentorship and action plans. -Collaborated with and supported management and representatives to develop or improve processes, job-aids, and a training manual for the Appeals Team while simplifying ways to deliver and train those processes. -Reported, tracked, and often exceeded daily casework goals in a variety of case types including internal Presidential and Executive cases and external entity cases such as CMS, BBB, and State of Florida Dept of Children and Families. -Mentored new, incoming Appeals Representatives to keep them on track with training objectives and help them develop key skills for success on our team.

• Grievance and Appeals Representative 3

  • May 2019 - Feb 2020

  -Resolved non-routine customer and partner appeals directly, with regulators and with employers, reporting findings to the appropriate business and functional areas to drive process and product enhancements. -Conducted last level audits on appeals cases, researching and investigating to validate classification/category and obtaining necessary information to help make proper, informed determinations.. -Responded to verbal and written appeals that involve complex matters submitted to… Show more -Resolved non-routine customer and partner appeals directly, with regulators and with employers, reporting findings to the appropriate business and functional areas to drive process and product enhancements. -Conducted last level audits on appeals cases, researching and investigating to validate classification/category and obtaining necessary information to help make proper, informed determinations.. -Responded to verbal and written appeals that involve complex matters submitted to CarePlus Health Plans and The Center for Medicare and Medicaid Services. -Managed large volumes of casework often assisting or mentoring coworkers for the department to remain compliant within internal and external timeframes.



Cigna Healthcare

• Hospitals and Health Care
• 700 & Above Employee

• Senior Eligibility Analyst

  • Oct 2016 - Feb 2019

  Doral, Florida, United States -Provide customer service to members, providers and employees from other Departments -Assist with the processing of member applications - Know and understand enrollment eligibility/elections -Able to read, understand and complete CMS Reports within established timeframe -Process member services request which include: demographic corrections, PCP/Center changes, ID card requests, Address changes -Audit work within the Department – work concurrently with daily error report -… Show more -Provide customer service to members, providers and employees from other Departments -Assist with the processing of member applications - Know and understand enrollment eligibility/elections -Able to read, understand and complete CMS Reports within established timeframe -Process member services request which include: demographic corrections, PCP/Center changes, ID card requests, Address changes -Audit work within the Department – work concurrently with daily error report - have Job Aids up to date – train co-workers on new procedures established by CMS or Cigna -Handle and if permitted resolve member complaints; obtain and evaluate all relevant information, and determine if it can be resolved by Enrollments or escalated to the Grievance Dept.

• Claims Processor Associate

  • Jun 2016 - Oct 2016

  - Research and process claims according to the processing guidelines and benefits - Provide assistance via email/phone to members, providers, and internal Departments - Verify coordination of benefits; request balance bills, Claims (UB forms), EOBs, - Contact and follow up with providers for additional correspondence such as: Medical Records, Itemized bills, W-9 Forms - Responsible for accurate and timely daily reports - Assists with training of new hires - Third Party… Show more - Research and process claims according to the processing guidelines and benefits - Provide assistance via email/phone to members, providers, and internal Departments - Verify coordination of benefits; request balance bills, Claims (UB forms), EOBs, - Contact and follow up with providers for additional correspondence such as: Medical Records, Itemized bills, W-9 Forms - Responsible for accurate and timely daily reports - Assists with training of new hires - Third Party Administrator knowledge and Experience - Knowledge of ICD-9, ICD-10 and CPT coding

• General Clerk Part D Associate

  • Jun 2015 - May 2016

  - Scheduled, and managed phone appointments for the Pharmacist, and ensured that the proper therapy regimen was used by the pharmacist (Medication Therapy Management) - Followed up with members to inquire on how the medications are making them feel, to determine if any changes may need to be made - Accurately entered patient information into the system to ensure the Pharmacists always had accurate data - Thorough working knowledge of HIPAA policies and procedures