 Lead, design, build, implement and support high quality technology-basedcompliance solutions (i.e., Risk Management, Incident Management, Appeals &Grievances, and Audit Management).  Influence technology direction based on deep familiarity with the healthcare compliance industry and technology trends, analytics, and research to advance our products and drive innovation.  Translate complex data sets into clear directional requirement documents, user stories, mockups, and UI/UX designs.  Evaluate and produce system requirements, identify substandard processes, recommend improvements, and test end-to-end business requirements  Communicate direction to the development team and stakeholders throughoutthe release/sprint.  Produce cross-functional test cases and perform quality assurance. Responsible to identify bugs, issues, defects, or mistakes in demo and productionenvironments.  Work with business owners to custom develop and write up user stories,acceptance criteria, feature description decks, user guides, training manuals,process flows, and wire frames.  Present, demo, and solicit feedback to clients and internal groups of all sizes.  Serve as a lead auditor and consultant in client compliance and CMS audits.

 Developed, edited, and performed quality assurance for enrollee regulatedmaterials for health plan clients producing accurate and timely materials.  Project managed client product offerings, benefits, and coverage to ensure regulatory material accuracy, review, compliance, and timeliness.  Served as a Subject Matter Expert on regulatory requirements for development ofmandated enrollee materials for clients, including Medicare and Medicaid. Subject matter expert and lead auditor on client projects related to CMS ProgramAudit needs.  Served as an interim consultant for a health plan client to build their VendorOversight Compliance Program and Auditing. Evaluate and produce system requirements, identify substandard processes,recommend improvements, and test end-to-end business requirements. Translate complex data sets into clear directional requirement documents, userstories, mockups, and UI/UX designs

 Lead and managed efforts to ensure compliance with Medicare Advantage lawsand regulations, contractual agreements, and compliance program requirements. Leveraged CMS regulations, audit protocols, and universe requirements toconduct internal and delegate audits. Consulted with internal departments by identifying where compliance risks mayexist, recognizing areas of improvement, and providing recommendations toimprove controls and limit potential non-compliance. Educated business on CMS Audit protocols and process. Conducted review and testing of Part C Organization Determination, Appeals, andGrievances (ODAG) and Compliance Program Effectiveness (CPE) universes andsamples to ensure data integrity and CMS program audit readiness. Prepared audit work papers and reports that effectively outlined findings andcorrective actions. Reviewed corrective action plans and consulted with the business on anynecessary changes. Investigated and resolved reported compliance incidents in Compliance 360. Conducted monthly/quarterly monitoring of high-risk compliance areas.

 Provided contract oversight activities for the Centers for Medicare & MedicaidServices (CMS) contracts. Collected and prioritized incoming regulatory and policy information, identifiedimpact, communicated, and coordinated required action with key departments. Project Managed CMS applications and contract process, CMS Annual Reporting,Data Validation, major regulation changes and CMS auditing and monitoringrequests. Managed federal requirements and provided guidance to internal departments onanalysis of federal regulations and regulatory communications, related toMedicare. Coordinated and performed Quality Assurance reviews and submitted requiredreporting to CMS. Prepared and organized documentation for CMS audits, including data samplesubmissions to CMS and internal review of policies and procedures as they relatedto the audit. Worked with internal departments to develop and monitor appropriate correctiveaction plans for identified issues until CAP closed by CMS. Created and updated department policy, procedure, and work instructiondocuments, including the step-by-step process for the use of the regulationsmodule in Compliance 360. Lead cross-departmental trainings for employees on managing tasks withinCompliance 360.

 Targeted, initiated, and discussed with providers the contract terms andconditions for government programs. Planned, directed, and drove provider recruitment activities that supported clientand network goals. Directed actions with other functional areas on contract set up and changes. Monitored competitiveness of provider networks within regional area ofresponsibility and take actions necessary to address any competitive gaps. Developed and maintain business relationships with key internal and externalclients. Provided advice/guidance/recommendations to senior management andfunctional areas regarding provider recruitment initiatives. Served as owner for provider communication pieces such as recruitment lettersand Plan Summaries.

 Investigated multiple escalated issues and quickly resolve Department ofInsurance and legal complaints/appeals filed by providers and members byperforming extensive research of member and provider claims history. Researched audit and recovery complaints, contract breach, HIPAA violation, andpotential fraud/abuse case complaints. Used a wide range of databases and people to assess claim dollar volume,network setup, contract status, and client expectations to establish resolutionstrategies. Developed project plan and design a solution and timeline for the resolution andimplemented the strategy that satisfied clients. Researched claims/contracts to identify root causes, propose corrective actionplans, and process improvement opportunities. Provided written resolution to insurance regulators, providers, members, legal andexecutive staff. Educated providers and teams on company policies, procedures, and contracts. Subject matter expert to internal and external clients in resolution of escalatedservice issues. Provided monthly, quarterly, and ad hoc reports to team. Audited cases monthly to ensure regulatory and internal requirements were met.