I review state laws and regulations that impact health care. I am also responsible for reviewing Medicare Advantage regulations and standards. I develop compliance work plans for impacted Magellan companies to ensure that the applicable laws and regulations are implemented and that all policies and procedures are compliant with such laws and regulations. I lead a corporate compliance audit team that conducts internal regulatory audits and I research compliance questions for our companies. I also review correspondence for compliance with applicable laws and regulations.

Management of the compliance program; oversight of a claim/appeal department and a complaint department.Compliance: Responsibilities included Implementation and oversight of compliance activities, including clinical and non-clinical appeals’ activities, and external appeal processes. Oversight of implementation of HIPAA regulations. Maintained information regarding state and federal regulatory and accrediting agencies’ requirements and implemented policies and procedures in to ensure compliance. Ensured member utilization management communication was compliant with state and federal regulatory and accrediting agencies’ requirements. Collaborated with the Training department to implement staff training regarding compliance with legislative mandates, accrediting bodies, Department of Insurance rules and contract requirements.Clinical: I provided supervision of behavioral health clinical Care Managers, Claims Specialists and clerical/technical staff in the Suspense/Retrospective Review Department. Provided oversight of all aspects of departmental operations, including review of provider treatment records according to specific utilization review criteria, resolution of appeals (standard appeals and reviews by an Independent Review Organization), customer inquiries, and specialized behavioral health claims’ processing.Complaint Department: I also supervised of clinical Care Managers, complaint coordinators, and administrative staff in a department responsible for researching and resolving Quality of Care and Quality of Service complaints, and administrative and claim appeals for multiple client health care companies. I provided oversight of the resolution of Department of Insurance complaints. I tracked and trending complaints in order to implement quality improvement initiatives. I was responsible for ensuring the department's compliance with regulatory requirements.

Provided supervision of behavioral health clinical Care Managers, Claims Specialists and clerical/technical staff in the Suspense/Retrospective Review Department. Provided oversight of all aspects of departmental operations, including review of provider treatment records according to specific utilization review criteria, resolution of appeals (standard appeals and reviews by an Independent Review Organization), customer inquiries, and specialized behavioral health claims’ processing. Researched and responded to sensitive complaints and inquiries, including legal cases and Texas Department of Insurance inquiries. Developed and implemented policies and procedures to facilitate the efficient operation of the department. Provided staff training. Worked closely with client company to meet performance expectations and to ensure quality service delivery. Provided timely reporting of outcomes to customers. The Behavioral Health Division of BCBSTX was purchased by Magellan Health Services in February 1998. I continued in this position at Magellan.

Reviewed provider medical records for compliance with behavioral health utilization review criteria/State of Texas chemical dependency criteria in order to approve treatment services for payment or to refer cases to Physician Advisors (clinical peer reviewers) for medical necessity determinations. Researched and responded to appeals of denied services in accordance with contract specifications/utilization review criteria. Researched and responded to sensitive complaints and inquiries, including legal cases and Texas Department of Insurance inquiries. Responded to crisis calls, providing crisis intervention services. Reviewed behavioral health claims requiring manual clinical review and specific claims for billing/coding errors using ICD-9 and CPT-4 coding. Reviewed claims for precertification and conformance to contract requirements. Responded verbally and through written correspondence to provider and subscriber complaints/concerns. I was promoted to Supervisor in May 1997.

Provided assessment services, brief therapy and referral for contracted companies’ employees. Participated with managed care organizations to provide precertification for outpatient and hospital based mental health and substance abuse treatment. Provided training for employees of contracted companies on a variety of mental health topics/issues. Responded to crisis calls, providing crisis intervention services.

Performed administrative and clinical supervision for children’s services staff, including children’s therapists, crisis interventionists and case managers. Developed and implemented goals and objectives for children’s programming. Planned and administered the budget for the children’s services division. Participated on the management team to develop and implement MHMR center-wide programs. Collaborated with local, county and state agencies in developing and implementing children’s programming, including performing duties as chairperson for legislatively mandated interagency clinical staffing committee (Community Resource Coordinating Group) and of a coalition of county agencies (Children’s Management Team.)

Counseled adults, adolescents and children for a variety of concerns, including personality, affective and adjustment reaction disorders, substance abuse issues and developmental life-cycle problems using individual, couple and family modalities in a private practice setting. Worked cooperatively with managed health care systems, employee assistance programs, county probation and supervision services, and the judicial system as well as various other community agencies to ensure quality client care.

Counseled university students and staff persons for personal issues and career concerns. Administered and interpreted vocational testing. Presented topical lectures to university classes. Provided weekly supervision to master’s level counseling graduate assistants and graduate interns.