Franchesca Radcliffe, Mph Email & Phone Number

Tampa/St. Petersburg, Florida Area

Maintain company URAC and NCQA accreditation and support compliance with customer and legal requirements relating to Delegated Utilization Management functions. Support accreditation and customer Delegation Oversight audit processes by reviewing and developing policies to comply with standards and preparing for and participating in accreditation and customer delegation oversight audits. Perform internal audits and identify opportunities for improvement; prepare audit tools and audit files; participate in NCQA and URAC audits; analyze data to identify and facilitate continuous improvement efforts to ensure compliance with accrediting, customer and legal requirements. Draft policies to ensure compliance with applicable legal and accreditation standards. Develop and deliver training to address improvement opportunities identified through audits. Monitor and communicate changes in accrediting standards and work with operational areas to implement changes required due to changes in accrediting standards. Work with Utilization Management operations to promote accreditation and customer Delegation Oversight audit success.

Tampa, Florida

Evaluate and identify compliance risk with contractual requirements. Conduct and provide support for regulatory audits. Review and evaluate the effectiveness of corrective action plans that address audit report findings and provide comprehensive follow-up to Senior Management and Compliance oversight committees. Track the status and completion of all corrective action plans and ensure implementation of all recommendations derived from each audit and subsequent report. Provide regulatory guidance to Sales and Marketing, Human Resources, Quality Improvement, Quality Compliance and Accreditation, and Case and Disease Management.

Identify individual requirements within executed contracts and assign responsible business owners to receive attestations of compliance. Evaluate the effectiveness of various compliance programs and related policies and procedures designed to promote legal and ethical compliance. Collaborate with other departments to direct compliance issues to appropriate channels for investigation and resolution. Educate, encourage and assist those within the Company to maintain integrity through oversight and monitoring and in meeting the requirements of the Annual Audit Plan within State Medicaid Programs, OIG and CMS work plan requirements.

Oversee Sales and Marketing compliance to ensure the enforcement of CMS (Centers for Medicare & Medicaid Services) regulations. Develop and present ideas for performance and process management improvement within the department; prevent, detect and resolve instances of conduct that do not conform to federal (CMS) and state law, and federal and state health care program requirements as well as ethical and business policies of the organization; act as a liaison between internal departments on data gathering and problem solving; facilitate communication among various departments.

Mph, Public Health

B.S, Biomedical Sciences

Minors in Biomedical Physics and Public Health