Celeste E. Email & Phone Number

New York, Ny, Us

Remote

New York, Ny - Remote

Philadelphia, Pennsylvania

While in this role, I directed the investigation of all Medicare regulatory and privacy (HIPAA) non-compliance issues, developing root cause analysis, final and beneficiary impact reports in collaboration with internal stakeholders. I executed internal mock audits and Centers for Medicare and Medicaid (CMS) Medicare Part D onsite program audits, evaluated results, and implemented improvement initiatives via training programs and enhanced oversight. I developed and presented to senior leadership all plan privacy reporting, issues of non-compliance and corrective action plans.Accomplishments in this role included:● Consistently reported newly identified privacy cases within 72 hours of discovery and of non-compliance within 14 days of discovery.● Reduced response time of monthly acknowledgment bulletin from 15 to 10 days.

Houston, Texas

I informed and managed the outcome of CMS appeals cases, rigorously researching and interpreting Medicare Managed Care Manual, Chapter 2, Chapter 13, and the Prescription Drug Manual, Chapter 18, and monitoring effectuation of all appeal and grievance process outcomes. I applied contract language, benefits and covered services in the research and decision process, and curated deliverables from operational areas in compliance with requests.

Sterling Heights, Mi

I led technical investigation and review of customer appeals involving provision of service and benefit coverage. Additionally, I collected and analyzed data, records, associated reports, and led appeals presentations to the advisory committee. In this role, I:● Streamlined internal response processes with the creation of appeals response templates and provided recommendations in appeal audits to monitor compliance.

Detroit, Michigan

I directed the investigation and resolution process of high-profile and sensitive inquiries. This included processing Part A, Part B and Part D standard and expedited appeals. I prepared written unfavorable and favorable appeal decisions and MAXIMUS redetermination response packets.My accomplishments in this role included being recognized as a top 3 performer for appeals review and response time, achieving a 97% work quality rating.

Detroit, Michigan

I researched, reviewed, and resolved Medicare and Medicaid member grievances across three states, clarifying and educating employees in the process in accordance with CMS guidelines, contractual obligations, NCQA guidelines, and plan policy. I authored and edited technical documentation for submission to MAXIMUS, IRO, external review, and state fair hearings and addressed appeal decisions by researching and summarizing regulatory and compliance guidelines. While in this position, I:● Drove the documentation of user requirements for MCS system development.● Achieved 100% quality rating and was designated as Medicare SME, selected to train other employees.

Certificate, Compliance Systems

Certificate, Paralegal

Certificate, Business Contracts

Bachelor Of Arts (B.A.), Telecommunications Management

Technical Diploma, Radio, Television, And Digital Communication

Master Of Business Administration (M.B.A.), Business Administration And Management, General