Responsible for the development, implementation, and oversight of the Compliance Program, focusing on the 7 elements of a Compliance Program outlined by the Office of Inspector General.

 Reports to the Plan President and Corporate Chief Compliance Officer, member of senior leadership Responsible for implementing, monitoring, and supporting a quality compliance program, including an extensive compliance work plan, governance, operational dashboards/scorecards, auditing, privacy, delegated vendor management, training, FWA and HIPAA oversight Provides oversight for operational processes with regard to Ohio regulations and requirements including project management of new implementations and remediation for existing areas of concern Oversees rule and regulation implementation and/or modifications and ensures that policies and procedures are adapted accordingly by establishing a Policy and Procedure Committee Performs audits of program requirements and regulations, including the implementation of Corrective Action Plans, if applicable Leads all activities related to the Ohio Department of Insurance including licensure and renewals Manages call center and appeal/grievance oversight to ensure compliance Facilitates responses to the Attorney Generals office and/or any other regulatory/legislative body regarding health plan inquiries, complaints, or data mining Responsible for FWA oversight including participation on the Ohio Healthcare Investigative Organization Participates on the Ohio Association of Health Plans Medicaid Committee and Legislative/Regulatory Committee

 Significantly reduced the number of backlogged pending pharmacy contracts by diligent redline/editing and successful contract negotiations Worked with numerous PBMs to effectively mitigate the impact of AWP Rollback for the 3600+ pharmacies represented; Reports to the Vice President of Business Development; member of the leadership team Provided oversight and analysis of contracting opportunities (New networks, amendments, addendums, renewals, etc.), improving contract outcomes including rates, terms, and conditions on behalf of 3600+ independent pharmacies Developed department workflow processes including procedures and various reporting tools Built relationships with pharmacy industry participants including PBMs, independent retail pharmacies, pharmacy chains, PSAOs, associations, Government entities, etc. Developed department workflow processes including procedures and various reporting tools Built relationships with pharmacy industry participants including PBMs, independent retail pharmacies, pharmacy chains, PSAOs, associations, Government entities, etc.

 Reported to the President & CEO and Board of Directors Built the Compliance, Government Contracts, and Appeals/Grievances infrastructure for a Medicaid Managed Care start up health plan Served as state liaison for health plan, attending conferences, committees, hearings , and technical assistance sessions and overseeing all written and verbal communication with the State of Ohio Developed Compliance Committee, Compliance Task Force, Appeal/Grievance Committee, and Policy and Procedure Committee which equated to more organizational consistency and ensured awareness of future contractual/compliance concerns  Acted as HIPAA Privacy Officer for health plan

 Oversaw the daily functions of contract facilitation for Medicaid Managed Care Plans including appeals and grievances, state hearings, monthly reporting, non-compliance, provider panel requirements, and consumer complaints Identified administrative efficiencies to reduce duplication and increase productivity Provided technical assistance presentations to various stakeholders including state agencies, community advocacy groups, and health plans Analyzed and modified applicable sections of the Ohio Administrative Code annually in conjunction with State Fiscal Year contract for Managed Health Care

 Provided oversight and reconciliation of Long Term Care billing for 6 Long Term Care facilities resulting in considerable savings to the state  Facilitated the consumer/attorney application process including the identification of improper transfers and unreported monies, preventing overspending by the state and financial savings Developed processes to reduce the amount of time spent on data entry, eliminating redundancy, and improving performance and productivity