Manager, Audit And Compliance
Current• Steered two (2) CMS Program Audits and four (4) Timeliness Monitoring Projects to confirm CareOregon Advantage’s compliance with Medicare reportable data reliability, validity, and completeness. Areas reviewed included: Compliance Program Effectiveness (CPE); Part D Formulary and Benefit Administration (FA); Part D Coverage Determinations, Appeals, and Grievances (CDAG); Part C Organization Determinations, Appeals and Grievances (ODAG); and Special Needs Plan – Model of Care (SNP-MOC).• Detected internal control weaknesses and payment errors exceeding $10 million annually in the provider Value-Based Payment process. Recommended realistic solutions to identify gaps and collaborated with operational management to develop plans to correct deficiencies. • Developed and implemented a Corporate Compliance Program to comply with laws, rules, and regulations as required by CMS. Created a Compliance Dashboard to provide comprehensive measures of operational requirements and evidences how the organization measures compliance.• Created annual risk assessment to identify compliance risks. Utilized results from the assessment and feedback from operational personnel to develop the annual audit schedule.• Conducted pre-delegation assessments of First Tier, Downstream, and Related Entities to verify the ability to perform delegated activities prior to contracting.• Represented the organization during Oregon Health Authority Medicaid Quality Reviews to evidence program integrity while interacting with regulatory auditors to address questions.• Administered the organizations HIPAA program, including performing assessments for reported privacy and/or security incidents and notification to the member(s) if a privacy breach occurred. Designed training material and conducted HIPAA training for onboarding employees.