Clinical Compliance Consultant Sr. - ELEVANCE HEALTH PLANS - Tampa, FL
(2013-04)
- Perform oversight of first-tier, delegated or related entities, including audits of credentialing files, documents, and activities reflecting compliance with accreditation standards, and regulatory requirements in all of the health plan's markets, also utilize the Health Industry Collaborative Effort (HICE) process to collaboratively perform oversight functions with various contracted health plans.
- Perform continuous monitoring of the delegate's activities and fulfillment of their contractual responsibilities.
- Coordinate with the delegates and internal business partners to ensure compliance with CMS, AHCA, NCQA, HIPAA, Medicare/Medicaid, and any other applicable regulatory requirements.
- Track and trend progress and review statistical status reports for monitoring ongoing projects.
- Identify root cause of issues and develop solutions for process improvements to ensure continued compliance.
- Prepare audit reports, including correspondence and corrective action plans, present audit findings to the delegation oversight committee.
- Review Departmental Policies and Procedures for the Delegation Oversight Audit Tools to corroborate compliance with multiple State requirements and Medicare/Medicaid and Commercial lines of business.
- Perform periodic training with internal business partners on delegation oversight processes and systems.
- Maintain knowledge of up-to-date NCQA, Federal, State, and regional standards and guidelines to ensure compliance standards are continually met.
Delegation Oversight Auditor - WELLCARE HEALTH PLANS - Tampa, FL
(2006-11 - 2013-04)
- Provided oversight of first-tier, delegated or related entities, including audits of credentialing files, disaster recovery and fraud, waste and abuse policies and procedures, documents, and activities reflecting compliance with accreditation standards, and regulatory requirements in all of the Health Plan's markets (CT, FL, GA HI, KY, LA, TX, NJ, NY, KY, IL, MO, OH and HI) as well as Corporate (Multiple States).
- Performed continuous monitoring of the delegate's activities and fulfillment of their contractual responsibilities.
- Coordinated with the delegates and internal business partners to ensure compliance with CMS, AHCA, NCQA, HIPAA and all regulatory requirements.
- Tracked and trended progress and prepared statistical status reports for monitoring ongoing projects for management.
- Identified root cause of issues and developed innovative solutions for process improvements to maximize efficiency and continued compliance.
- Performed periodic training with internal business partners on delegation oversight processes and systems.
- Assisted in reviewing the Policies and Procedures for the Delegation Oversight Department to assure compliance with multiple State requirements and Medicare/Medicaid regulations.
- Reviewed Delegation Agreements for all delegated entities.
- Maintained knowledge of up-to-date NCQA, Federal, State, and regional standards and guidelines to ensure compliance.
- Prepare audit reports, including correspondence and corrective action plans if applicable, present audit findings to the delegation oversight committee.
Credentialing Specialist - WELLCARE HEALTH PLANS - Tampa, FL
(2004-06 - 2006-11)
- Reviewed and processed credentialing and re-credentialing files.
- Performed primary and secondary source verifications of providers' credentials with special emphasis on provider issues relating to malpractice claims, privileging, criminal concerns, license anomalies, and discrepancies in education.
- Provided written summaries of problematic files and prepared clean files for presentation to the credentialing committee, conducted research, and prepared correspondence.
- Continuously met productivity quotas daily.
Credentialing Assistant - WELLCARE HEALTH PLANS - Tampa, FL
(2001-02 - 2004-06)
- Coordinated intake of credentialing and re-credentialing provider and ancillary files.
- Performed monthly database query, obtained verifications of licenses and DEA certificates due to expire, and updated the databases to reflect updated licensure information.
- Documented the number of credentialing and re-credentialing files being assigned and processed daily.
- Processed incoming and outgoing communications to providers and internal business partners.
Weekend Concierge/Front Desk - MONTE CARLO TOWERS - Tampa, FL
(2019-10)
- Answers phone, greet residents and guests in a friendly manner. Assist residents with reservations and updating their building link profile.
- Log, sort, and organize incoming packages and deliveries for residents, ensuring packages are logged and delivered accurately.
- I interact with residents and staff to address any issues or concerns of residents; monitor emergency response system when there is an alert to the fire alarm panel.
- Communicate with the maintenance team to address any reports or maintenance issues reported by residents and staff. Update Building Link to document work orders, incidents, and any identified issues.
