Donna Mcintosh Email and Phone Number

Supported the annual planning efforts and the execution of the 3-year annual business plan that includes internal and external communications and associate engagement activities. Program responsibilities such as executive reporting, project communications, management of issues logs and change requests, facilitating project meetings, managing deliverables and ensuring resolution of escalated issues. Developed and coordinated presentations and materials for executive management meetings, internal and external speaking engagements and meetings. Responsible for the implementation and execution of strategy that includes change management, sponsorship and buy-in and advocacy efforts to get business results.

Responsible for implementing the Corporate Compliance Plan (CCP) at the health plan level that serves to prevent and detect crime, to promote compliance with corporate policies and upholds ethical culture. Lead and assure compliance training activities are completed in an effective manner. Monitor health plan performance standards for compliance with contractual and regulatory requirements and maintain a general focus on call center metrics, claims payments, minimum net worth and licensure of health plans and employed professional. Review policies and procedures and health plan activities to ensure adherence to Business Associate requirements and physical and electronic security under HIPAA. Facilitate regular meetings of the Plan Compliance Committee to discuss identification and assessment of compliance initiatives, potential risks and current state. Serve as liaison to external and internal audits between business owner and state/federal entities. Coordinate with the Office of Business Ethics (OBE) on preliminary investigations of potential non-compliance; maintain confidentiality as appropriate and recommend corrective action or next steps to OBE and business owners. Monitor corrective actions related to issues identified at the plan level. Serve as a compliance advisor to the plan CEO.

Sr. Director, Compliance (2012-2013)Oversaw and managed programs, policies, and practices to ensure ongoing compliance with the state Medicaid contract. Enforced Centene policies and procedures, Medicaid regulations, and all other federal, state and local regulatory requirements. Ensured Peach State Health Plan’s (“PSHP’s”) timely response to the Department of Community Health (“DCH”) ad hoc requests, corrective action plans (“CAP”) and various deliverables, while overseeing the issue resolution process. Managed and coordinated PSHP’s fraud and abuse activities. Developed and facilitated Compliance Training Programs and provide compliance oversight to delegates. Served as the HIPAA Compliance Officer ensuring HIPAA compliance for a staff of 200+ employees by conducting quarterly desk audits and monitoring disclosures. Represented the health plan at state and local government meetings. Oversaw all compliance related activities with Peach State’s Medicare Special Needs Program (SNP). Oversaw and managed both internal and external plan audit requests. Monitored plan related risks.

Director, ComplianceOversee and manage programs, policies, and practices to ensure ongoing compliance with the state Medicaid contract. Enforce Centene policies and procedures, Medicaid regulations, and all other federal, state and local regulatory requirements. Ensure Peach State Health Plan's ("PSHP's") timely response to the Department of Community Health ("DCH") ad hoc requests, corrective action plans ("CAP") and various deliverables, while overseeing the issue resolution process. Manage and coordinate PSHP's fraud and abuse activities. Develop and facilitate Compliance Training Programs and provide compliance oversight to delegates. Serve as the HIPAA Compliance Officer ensuring HIPAA compliance for a staff of 200+ employees by conducting quarterly desk audits and monitoring disclosures. Represent the health plan at state and local government meetings.

Manager Regulatory/ComplianceSupervised and managed resources to ensure the effective administration and compliance with the Department of Community Health contract, laws, regulations and policies that direct government programs. Served as a liaison between the corporate office for Corporate Compliance and Regulatory Affairs activities, including serving as a principal point of contact and responding to internal audit requests. Functioned as the fraud and abuse liaison for the Department of Community Health ("DCH") Program Integrity Division. Tracked and resolved all issues referred to the Regulatory Affairs Department via various mediums. Coordinated filing of regulatory report deliverables. Researched and interpret policies and regulations and inform various departments of their obligations. Responded timely to the Department of Insurance ("DOI") Consumer Complaints and DCH ad hoc requests and deliverables. Supervised and managed resources to adhere to administrative law hearing requests set with the Office of State and Administrative Hearings. Ensured associates completion of on line compliance and ethics training and ensured continuous understanding for the Georgia market.

Served as the fiscal agent to the Department of Community Health (DCH) Program Integrity Division. Provided functional and technical analysis in support of project scope and objectives concerning Medicaid claims processing. Offered expertise in the area of fraud and abuse and managed care to the client and internal associates. Performed research activities to identify new and evolving fraud schemes. Designed, coded and produced Medicaid Fraud & Abuse reports using an in-house query tool for DCH. Provided superior customer service to the client. Completed quality assurance checks for deliverable items to the client. Worked collaboratively with subcontractors to provide project requests to DCH.

Managed and coordinated the training and work activities of 4+ employees as well as the timely and efficient review of cases, procedures and practices. Interfaced with internal departments to provide information and assistance while preparing proposal request and bids. Prepared and maintained documentation and other materials for investigations, in conjunction with law enforcement and other government agencies.· Received numerous commendations from customers and client companies for providing outstanding assistance in resolving suspected fraud issues.· Successfully maintained the workload of a Fraud and Abuse Analyst while concurrently handling managerial functions of the Fraud Investigations Department.· Created and implemented a corporate web-based E-Learning system for fraud awareness training that was approved by upper level management.