| Experience | Confidential Compliance Consultant, Appeals - Ensured compliance with existing laws, regulations and requirements.
- Researched, investigated, and evaluated compliance implementation initiatives and required remediation initiatives.
- Conducted risk assessments and audits and monitor department/divisional systems for compliance. Ensured appropriate implementation and corrective action was taken to address risks and issues identified in partnership with Corporate Compliance.
- Analyzed and assessed departmental environment and compliance program and system needs. Recommended compliance programming and compliance initiatives in consultation with Corporate Compliance
- Redesigned and Managed Appeal Department SharePoint Redesign Project to improve tracking and updating of Job aides, procedures and information. The project made the SharePoint a training aide for new hires and cross training of analysts.
- Facilitated Monthly Meetings and Workgroup meetings: Appeals Department SharePoint Workgroup, Appeal Department/ InterPlan Programs JOC meetings, including representing Provider Appeals Department in Company QIC meetings and project meetings.
Confidential Quality Auditor, Claims Review Training - Policy - Performed weekly and monthly departmental audits.
- Performed Focus Audits of system and customer service representative processes.
- Performed SAS70 High Dollar Audits that reviewed Financial Risks and ensured Financial Accuracy.
- Reported Audit Findings and Trends to Management through Database Storage and Weekly Reporting.
- Developed Couching Clinics that addressed and educated customer service representatives of audit findings and correct operational procedures and processes.
Confidential Compliance Specialist, Regulatory Compliance - Selected for Special Project to assist with Thomas Love Litigation review of organizational policies, laws and regulations.
- Supported Director of Compliance with implementation of high ethical and compliance standards and assured regulatory compliance at BCBSNC through audit programs and projects.
- Managed 5 complex, highly visible cross-functional projects to ensure compliance with new and existing laws and regulations.
- Assisted with deployment of corporate compliance programs through training, audits and assessments, investigations, NCDOI examination support and legislative implementations.
- Identified compliance risks throughout the company through internal mock audits, reviewing and analyzing findings while documenting company processes and procedures.
- Worked on compliance team in the development and implementation of corrective action plans to be review and signed by executive management for company approval during annual reviews.
- Conducted internal audits and compliance reviews in order to mitigate risks related to regulatory audits performed by state regulators and third party vendors.
Confidential Business Analyst, InterPlan Programs Compliance - Managed resolution of Compliance issues/projects that resulted in process improvements and business efficiencies.
- Conducted and disseminated policies to support InterPlan Programs business.
- Developed target standards and timelines to in accordance with unit, departmental and divisional goals.
- Conducted AS IS, gap, and lean assessments of InterPlan Operation that resulted in process improvements.
- Prepared business cases, business requirements, root cause analysis, and risk assessment controls evaluations on BCBSA, Corporate, and Operational Excellence projects.
- Prepared management and executive compliance reports.
- Led InterPlan Program SAS-70 Claims Balancing Project - ensured accurate reporting, explanation of claim systems data, and risk mitigation through group walkthrough meetings, which included system overviews, review of control matrixes in place, alone with audit review sessions with external vendor, PWC. Prepared and submit Final SAS-70 report for department.
- Served as an Advocate and Liaison for InterPlan Operation end-user requirements and ensured project implementations met business need.
- Served as Business Liaison with Project Managers and communicated progress reports to business.
Confidential Interim Team Lead, InterPlan Operation Operation Specialist, InterPlan Operation - Managed daily workflow to achieve index goals. Took appropriate actions to follow through on open inventory.
- Handled customer inquiries regarding claims, membership, billing, and other issues. Researched and responded promptly, courteously, and thoroughly to all inquiries.
- Identified quality issues and training needs for InterPlan Programs.
- Designed and implemented training course for new employees. Identified, documented and escalated system and process problems. Thoroughly analyzed issues, determined root cause and recommended remediation to business.
- Provided feedback for operation improvement on human errors to associates.
- Processed all phases of claims adjustments to reflect appropriate certificate liability.
- Reduced aged inventory, escalated calls and issues from, other Blue Cross Plans and InterPlan Operation.
- Dedicated representative for Duke University Medical Center to resolve their concerns issues with outstanding BlueCard out-of-state claims.
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