Ingrid Vargas Email and Phone Number

Compliance Specialist is responsible for performing internal audits monthly to ensure all departments meet their compliance benchmarks and their business activities are in compliance with all state and federal regulations and health plan contracts requirements. Act appropriately to support and implement the Argus Compliance Program, Standards of Conduct, and Code of Ethics. Assist with monitoring and auditing compliance metrics required of the various Argus departments. Research federal and state regulations and provide education to the various Argus departments on new regulations that can/will affect the department. Participate in preparation for and execution of internal audits, health plan audits, and accreditation surveys. Assist the Compliance Manager with annual/routine Compliance/HIPAA/FWA training and Risk Management training. Work closely with the Compliance Officer to assist with Argus projects that require monitoring department process improvement. Support the leadership team by providing sound feedback and research findings for process improvement. Help the Compliance Officer with implementing the Compliance Work Plan and assisting with monthly reporting of Compliance/HIPAA/FWA and Risk Management efforts and investigations. Stay informed of industry trends and regulatory requirements.Provide assistance at all levels of operation as needed in order to complete projects on time and stay in compliance with Argus and regulatory/health plan requirements.Assist the Compliance Officer with all business documents, including health plan contracts.

Responsible for working and reconciling the membership data of the health care exchange business carriers (Health Plans) that HPS serves. Ensure membership data is correct and accounted for and variances can be identified, root-caused/explained, and ultimately reported and remediated. Daily, monthly, and APTC (Advanced Premium Tax Credit) reconciliation.• Analyze daily summary reporting of processed enrollment transactions received from the Exchanges to identify discrepancies.• Analyze daily summary reporting of received enrollment transactions to ensure receipt of all transactions.• Identify/analyze/root cause discrepancies between enrollment/eligibility files (834 transactions) and payment files (820 transactions) .• Daily working of membership data discrepancies between the Health Care Exchanges and HPS; Between HPS and the Carriers.• Understand Federal and State regulations to ensure accurate interpretation and processing of data.• Work daily exceptions and failed transactions and communicate to internal departments, federal, and state exchanges as needed.• Ability to communicate effectively and efficiently of tracked high risk discrepancies to management (i.e. early detection, trend identification).• Communicate clearly with Carrier partners any discrepancy concerns and provide resolution in a timely and equitable manner within the guidelines of company policies and procedures, as well as Federal and State Regulations.• Create and update Step Action Procedures as needed for business processes.• Understand complex EDI (Electronic Data Interface) transactions to be able to ascertain where potential problems lie.• Be able to read and interpret Business Rules for automated processing of transactions .

Coordinates and maintains the online evidence of compliance for accreditation and AHCA. Coordinates various administrative functions for the Quality Improvement Department and production and timely completion of projects as appropriate.Participates in formal committee and management meetings, takes detailed minutes and disseminates to appropriate participants. Acts as a liaison and representative for management in these situations. Generates and analyzes reports and charts on a daily, weekly and monthly basis as directed.Participates in the planning process of leadership meetings and accreditation training programs.Coordinates various administrative functions for the Quality Improvement Department. Responsible for updating and maintaining documents for the governance of the organization. Maintain department policies and data repository.Supports both PMAP and PIP documentation – including preparing documents and presentation of data.Assists in creating job-aids for new and revised processes.Assists with annual program documents.Builds and maintains cooperative business relationships both internally and externally, participating in vendor selection, contract negotiation, implementation and performance monitoring related to HEDIS measurement and reporting.Support annual HEDIS, Gaps in Care and HSAG activities.

Conducted home visits to complete face-to-face Health Assessments for all member ensuring members are receiving quality health care and utilizing benefits.Referred members to case management for care plan, in conjunction with the Ohio Department of Job and Family Services and the Performance Improvement Project (PIP).Created awareness programs describing services and healthcare options, providing optimum accessible information for both English-speaking and Hispanic populations.Coordinated community resources with emphasis on the development of natural support system and coordinated benefits, regulations, laws and public entitlement programs, assisting clients with full information options.Assisted and Team Leader with QI department monitoring progress with Early and Periodic Screening, Diagnosis and Treatment (EPSDT) requirements, initiating viable outreach plans for members and increase health outcomes.Worked directly with members and providers to ensure Emergency Diversion Program requirements are met in order to decrease emergency use.Trained new member outreach coordinators on outreach efforts, program systems, and quality improvement initiatives.Responded to member grievances to the State in a timely manner.Conducted HEDIS Field Medical Record Reviewer visit physician’s offices and medical facilities to retrieve, review, and pre-audit specific documents from medical records for various projects and studies. Outreach to Medicare members to ensure compliance measures and quality health scores were met.