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Click here or scroll down to respond to this candidatePage 1 of 3Page 1 of 3Candidate's Name
PHONE NUMBER AVAILABLE EMAIL AVAILABLE Dallas, TX LinkedIn CHIEF COMPLIANCE OFFICERCompliance & Risk Management Policy Development & Implementation Regulatory Analysis Strategic Chief Compliance Officer with 20+ years experience rebuilding, establishing, and integrating comprehensive enterprise-wide compliance programs in dynamic, matrixed healthcare organizations. Effective at identifying and analyzing organizational risks, assessing policies and procedures, developing, implementing, and managing compliance programs, and recommending opportunities for monitoring internal systems and controls to achieve compliance objectives. Visible, approachable, and transparent leader and strategic business partner adept at collaborating with stakeholders across all organizational levels to implement effective compliance programs. KEY ACHIEVEMENTSDesigned and implemented strategies and programs supporting targeted goals and accommodated state and federal regulatory and contractual requirements resulting in a compliance increase from 30% to 98%.Established and effected the program integrity plan by founding the Special Investigations Unit, the key component of the organization's effective compliance program enhancing compliance and minimizing risk.Spearheaded the execution of Medicaid carve-in benefits, external medical review process, and large-scale readiness review for the Claims system reviewing 100+ deliverables over 6-month review period. CORE COMPETENCIES Regulatory Policy Development Compliance Program Infrastructure Strategic Planning & Development Enterprise Risk Management Process Improvement Vendor Management & Contract Oversight Stark & Anti-kickback Compliance HIPAA/HITECH Government ProgramsPROFESSIONAL EXPERIENCEParkland Community Health Plan Dallas, TXChief Compliance, Ethics, and Privacy Officer 2020 - Present Developed and effected comprehensive compliance and integrity program for Parkland Community Health Plan, ensuring alignment with state and federal regulations. Addressed business operations and strategic initiatives as member of the Executive Leadership Team. Conducted comprehensive assessment of organizational risks and compliance gaps, monitored and managed operations performance, identified compliance and regulatory deficiencies, and reported to the CEO and Board of Directors. Established and executed the program integrity plan, including founding the Special Investigations Unit, addressing OIG requirements, and enhancing organizational compliance. Spearheaded compliance improvements through the realization of the Payment Integrity Program and implementation of post-pay reviews, DRG audits, and FWA data mining resulting in enhanced error detection capabilities and minimizing risk. Effected the organization's first Privacy Program after assessing organizational risks and compliance gaps, developing robust compliance and privacy program infrastructure. Led the execution of Medicaid carve-in benefits, external medical review process, and large-scale readiness review for Claims system reviewing 100+ deliverables over 6-month period. Formulated compliance and privacy program infrastructure, including staffing, compliance work plan, audit plan, compliance investigations, all policies, and reporting management tools and processes. Conducted external audits and communicated results to regulators while actively monitoring corrective action plans for timely resolution. Partnered with regulatory bodies, including the Office of Inspector General, Texas Attorney General and HHSC as the primary point of contact, establishing and maintaining effective communication channels. Care N' Care Insurance Company/North Texas Specialty Physicians Fort Worth, TX Compliance Officer/Director of Government Programs 2014 2020 Served as an organization-wide resource for Compliance program guidance and maintained working knowledge of Federal and State regulations, requirements, and policies. Implemented a comprehensive oversight program for First Page 2 of 3Page 2 of 3Tier, Downstream, and Related entities, encompassing delegated entity oversight, internal monitoring, corrective action plans, audit activities, market conduct compliance issues while reporting to the CEO and the Board of Directors. Served as chair of the compliance committee. Advanced Compliance Programs in Texas and North Carolina through policies, program description and oversight management tools and processes developing compliance infrastructure. Assessed the status and effectiveness of the Compliance and compliance training programs and reported to the Board of Directors and executive leadership with proposed solutions. Coordinate training with Human Resources to keep officers, directors, employees, and other stakeholders knowledgeable on the Compliance Program, Code of Conduct, applicable policies and procedures, and applicable statutory and regulatory requirements. Reported potential fraud or misconduct to CMS, its designee and/or law enforcement, as appropriate and maintained comprehensive documentation, as directed by Federal and state agencies, for reporting potential fraud, waste, and abuse received through proper reporting methods. Facilitated compliance with the Code of Conduct, OIG Exclusions screening, implementation of the Compliance Hotline, and investigating all instances of reported misconduct. Collaborated with the HIPAA Security Officer to ensure compliance with Federal and State Privacy regulations, including HIPAA & HITECH policy and procedures.Kaiser Permanente Atlanta, GACompliance Officer 2007 - 2014Administered the regional compliance program for Kaiser Foundation Health Plan of Georgia and The Southeast Permanente Medical Group, assuming full responsibility for its effective implementation and performance. Influenced comprehensive compliance adherence by serving as the central point of contact for the Centers for Medicare & Medicaid Services (CMS), maintaining a robust process to prevent compliance breaches. Guided strategic direction, coordination, and meticulous oversight of all compliance activities, including monitoring of excluded individuals and entities, ensuring alignment with organizational goals and regulatory requirements. Designed, modified, and implemented system-wide policies and procedures in response to legislative changes, facilitating smooth transitions and compliance across all functional areas. Identified potential areas of compliance vulnerability and risk by reviewing and researching State and Federal regulatory guidance and offering appropriate suggestions on areas of improvement. Coordinated all internal and external audits, managing the development and implementation of corrective action plans for resolution. Facilitated staff proficiency and understanding of compliance requirements by implementing training programs in accordance with policy, minimizing risk to the organization's operations. Program Manager, Accreditation and Regulation 2006-2007 Managed ongoing processes to ensure quality program compliance with regulatory and accrediting agencies and review bodies, including the National Committee for Quality Assurance (NCQA), the Center for Medicaid and Medicare Service, and the Department of Human Resources (DHR). Realized Medicare Deeming status from NCQA, leading the first Kaiser Permanente Region to accomplish this milestone with a survey free of findings. Established the Regional NCQA Steering Committee, fostering collaboration and strategic alignment in compliance efforts. Conducted a comprehensive assessment of regulatory standards, utilizing SWOT Analysis and Crosswalk approaches for thorough compliance evaluation. Developed and reviewed the Delegated Agreement Procedure Manual, ensuring streamlined and effective oversight of delegated activities.Business Edge Solutions Atlanta, GAConsultant, Program Management Office 2004 - 2006Managed the project plan, allocated resources, and coordinated multiple functional work groups and project work streams. Ensured strict compliance with service level agreements, adeptly handling vendor contract management, and adhering to state and federal regulatory requirements. Executed complete billing system conversion as the Executive Consultant, driving program planning and overseeing all components of the standard development lifecycle. Monitored and reported costs to maintain adherence to the project budget for 15+ project teams, including project managers, requirement analysts, developers, testers, and implementation managers. Created training manual for internal testers and customer service support staff and project communication manual specifically for the Organizational Change Management team promoting effective change adoption. AETNA, INC. - Alpharetta, GAPage 3 of 3Page 3 of 3Consultant 2000-2004Conducted Medical Underwriting, reviewing medical claims history, identifying risks, and assessing the value of high claimants. Scaled small group caseload from 50 to approximately 200 cases per renewal period, demonstrating exceptional growth and client retention for new and existing businesses. Researched economic and financial issues, recommending policy changes that enhanced rating and profitability. Tested the implementation of a new quoting and renewal system, streamlining processes and improving efficiency.EDUCATION & CERTIFICATION Master of Business Administration, Troy State University, Troy, AL Bachelor of Science in Health Care Management, Clayton State University, Morrow, GA Certified in Healthcare Compliance (CHC)PROFESSIONAL AFFILIATION United Way of Tarrant County, Area Agency on Aging Advisory Council Member |
