In my past role, I coordinated compliance activities within department, ensuring adherence to set timelines. I supervised approval process for marketing materials and facilitated communication with CMS, while providing recommendations on material approval. I cultivated relationships and communication with FDRs. Moreover, I provided support for utilization management and appeals and grievances during CMS program audits. I incorporated all operational departments into meetings alongside business analysts to rectify and submit precise data for CMS Data Validation. I also oversaw FWA department and managed HIPAA violation incidents. I organized simulated audits to enhance preparedness and compliance.• Developed annual audit plan tailored to delegation oversight requirements in compliance with CMS standards and pertinent federal or local regulations.• Established and enforced standards, guidelines, and performance metrics to ensure adherence to existing policies and procedures.• Formulated audit plans for First Tier, Downstream, and Related Entities (FDRs) based on risk assessments.• Ensured compliance with CMS notifications and requests for actions.

I reviewed and updated policies and procedures annually to ensure compliance. I monitored projects, involving technology and system configuration changes, including coordinating cross-functional testing.Furthermore, I managed projects for preparation of annual ODAG and CDAG reports. I facilitated initial and ongoing training sessions for all health plan employees. I oversaw audits across various departments, including enrollments, appeals, grievances, utilization management, marketing, and human resources. I also assisted compliance manager in implementing comprehensive audit plan for startup health plan.• Executed regular audits of all contracted FDRs and ensured compliance with health plan standards.• Investigated marketing allegations, incidents of FWA, and HIPAA breaches.

I conducted audits across multiple areas within enrollment and premium services to ensure compliance with established policies and procedures. I formulated statistical reports to identify need for additional training among existing employees. I administered projects of technology and system configuration changes, while overseeing cross-functional testing of applications. I also supported month-end close procedures by completing specific fiscal schedules and acting as backup to financial analyst.• Coordinated quality improvement initiatives for commercial, Medicare, and individual product lines.• Developed educational opportunities and training sessions to foster staff growth and development.• Led compliance auditing for both commercial and Medicare lines of business.

I reviewed and revised internal policies annually to ensure compliance and effectiveness. I managed both new and ongoing departmental projects. I monitored data population and sample preparation for internal and external audits. I performed interviews and made hiring decisions for new employees in both departments. I trained all staff members on new processes and procedures.• Oversaw team of 14 employees in both enrollments department and the mailroom, providing supervision and management.• Implemented cross-training initiatives for entire department staff, promoting versatility and proficiency across processes.• Generated and delivered operational reports on weekly, biweekly, and monthly basis to upper management.• Enhanced efficiency and consistency by pioneering development of job aides for all departmental roles.• Created and deployed executive dashboard for organization's use.

I managed team of four appeals coordinators by providing supervision and guidance. I assisted both members and providers in navigating and processing appeals with plan. I also conducted training for new hires covering all departmental processes. I supported business analysts in updating ODAG tables. I led daily, weekly, and monthly audits of internal processes to ensure compliance and efficiency.• Served as interim A&G supervisor for three months to oversee operations until appointment of permanent manager.• Acted as subject matter expert for CMS program audit, while providing valuable insights and assistance.• Generated and delivered biweekly and monthly operational reports to upper management.

Performed accurate data entry in order to effectively process enrollments and provide outstanding customer service telephonically to explain eligibility issues.• Consistently achieved 90% or above on quarterly performance evaluations.• Performed daily and weekly audits on internal processes and trained new hires in procedures.• Input and audited patient demographic information to ensure accuracy.

Accurately and efficiently sorted and distributed mail to all departments within the organization, utilizing mail room equipment safely and effectively to do so.• Effectively trained and supervised a high performing staff of three.