Andranathea Cherita Perez
Phenix City,AL
Summary
A highly motivated, self-sufficient, detail-oriented leader that demonstrates the ability to work both independently and collaboratively requiring little or no direction to complete tasks. Experienced auditor with strong work ethic in a high-performance culture, excellent organizational and time management skills, pro-activeness, and ability to produce results and meet required deadlines. Enjoy a challenging work environment with over 15 years of combined leadership, quality and compliance expertise in diverse industries including the healthcare sector, performing audits for internal and external clients. Flexible, fast-paced learner that can adapt quickly who is excited and passionate about researching and understanding business needs. Committed to excellence, doing the right thing, and living with integrity. I live out our mission. I act on our values. I make an impact
Overview
10
10
years of professional experience
Work History
Compliance Manager
Elevance Health
Midland, Georgia
01.2023 - Current
- Perform management and oversight of various Medicaid external regulatory audits, exams, and different types of internal and external audit activities performed by regulatory agencies or outside contractors, such as the Centers for Medicare and Medicaid Services (CMS), Department of Insurance (DOI), Department of Health and Human Services (DHHS), and State Medicaid Agencies, as well as Elevance Health’s Internal Audit (IA) department
- Partners with the Medicaid Business Advisory Team (BAT), the Risk and Issue Monitoring and Oversight (RIMO) team, Internal Audit, Legal, and responsible business areas
- Responsible for creating records in C360 for new external regulatory audits, updating the records regularly, and documenting outcomes of the audit such as findings, external corrective action plans (eCAPs), and fines
- Provide high-level details on current audits, closed audits, anticipated audits, fines/sanctions, and other data points for monthly audit roundtable report, and Medicaid Compliance Committee (MCC) report
Regulatory Compliance Consultant
Elevance Health
ALOPW
01.2022 - 01.2023
- Support Medicaid Marketing Strategy & Planning (MSP) and Creative teams to ensure compliance and oversee compliance-related initiatives supporting Phase and Function operations
- Regulate process source of truth (SoT) and resource documentation within MSP
- Owner of SharePoint edits, maintain CMAP Contact and Reviewer Lists, cheat sheets, brain dumps and other reference documents by the MSP and Creative departments
- Support implementation projects by assisting team process bulk updates and consulting on compliance matters for phase leads, market leads and team
- Project Lead and Consult for mandated materials for Privacy, NOPP updates, Standard Annual Notifications (SANs) and New Member Packets (NMPs), Babel Sheets and HHS notice updates and HIPAA Auth Forms
- Address CMAP process and resource standards gaps to ensure production of reliable, quality work
- Participate in meetings and provide input and solutions on compliance issues
- Interface with external clients, regulators, vendors, supplier; internal stakeholders and high level of management
- Maintains knowledge of laws, regulations, and possible impact to member collaterals by reviewing C360 alerts for requirement changes and organizes department Policies and Procedures
- Train upon request and provides annual training on required topics, such as Privacy or Telephone Consumer Protection Act (TCPA)
- Manage overdue CMAP report, create pivot table and distribute to PMs weekly
- Research contracts and regulation requirements, provide analytical support to projects, initiatives, regulatory audits or internal audits, accreditations, on-site reviews, risk assessments and ad-hoc audits
- Support state audit engagement and deliverables, network with Audit Center of Excellence (COE), Privacy and other business partners to ensure MSP is managing annual audit requirements
- Maintain reporting request form, Active Material Reports for JO and WF, format in Excel per request, meet report SLAs and pull materials as needed
- Serves as process SME
Compliance Consultant
Anthem
ALOPW
01.2021 - 01.2022
- Completed audits for CA DMHC G&A, including BH Standard and BH PQI assigned cases to ensure business unit accuracy and timeliness
- Conduct end-to-end assessments on high-risk areas G&A and UM by reviewing policies and procedures, operational guidelines and training and communication tools
- Responsible for delivering and executing foundational compliance responsibilities that support the team and management at the advanced level for CSBD
- Making sure business partners have all regulatory requirements so we meet those requirements
- Identify gaps that could be a risk and work with compliance manager to help remediate gaps and ensure what business unit provided as remediation is sustainable
- Report, communicate, research laws at the advanced level, regulations, requirements, regulatory audits and/or exams
- Conduct investigations, document findings, update stakeholders and leadership on developments, comply with notification requirements and ensure corrective actions are made
- Collaborate with other areas within the Enterprise to identify compliance best practices, adopt those best practices where applicable
- Improve business partner knowledge, reporting, remediation, and prevention of concerns affecting us from demonstrating an effective compliance program
Performance Quality Analyst II - MTM
Anthem
Midland, GA
02.2015 - 02.2021
- Audits the activities of various departments for compliance with plans, policies and procedures prescribed by management
- Tracks and trends audit results, providing feedback to management and associates while identifying improvements and offering recommendations for corrective action to manager
- Ability to interact regularly with business partners showing proven audit results, research Ops problems and system issues, identifying process improvement opportunities and passionate analytical skills in order to get to the root cause and determine resolution in order to help minimize errors
- Audit multiple systems and multiple lines of business for accuracy, enrollment and timeliness measures for member and provider inquiries including Commercial, National, Individual, ACA, Medicare and Medicaid in WGS, GBD Facets and MEDISYS for MTM Compliance program by monitoring claims processing, customer service and enrollment processing functions of substantially all branded, core health business for BCBS License Agreements between Plans and the Blue Cross Blue Shield Association (BCBSA)
- Proficient viewing and locating provider contracts using Anthem Provider Search ICN Tool, Provider Contraxx Ecteon Tools, MACESS & PCR Medicaid and WCF Provider Contract Tool
- Experienced using SQL and MARx database via CMS portal
- Provides onsite/virtual training, guidance and coaching to Performance Quality Analysts (PQA), facilitate New Hire presentations, partnership meetings, calibrations, lead projects, mentors, and acts as a leader for the team and business by interpretation of Inline and MTM Compliance guidelines, audit process and answering questions or providing guidance around the audit process to operational areas
- Functions as subject matter expert (SME), creating team workload, administering 100% audit-the-auditor (ATA) for new PQA and training new analysts and managers on the SCORE database, pulling reports, facilitate and providing expertise in response to day-to-day business issues while managing work and participating in special projects as necessary
- Expert for discrepancy review, respond to questions from peers, communicate and coordinate with business partners based on their needs
- Provides timely information and decisions, excellent analytical, presentation, written and verbal communication skills in addition to sound decision-making skills
- Identifies and reports on systemic issues which create ongoing quality concerns
- Analyze reports of audit findings, supports clients with issues identified and develops reports to assist management with information requested as needed
- Produce other ad hoc reports as requested by internal and/or external clients
- Acquire and perform progressively more complex skills and tasks in a production environment
- Proven understanding of different audit methodologies, processing principles, techniques Certified Open Enrollment Ambassador, HYPE/APEX/WIN ARG member
Education
Graduate Certificate - Health Care Compliance And Privacy
University of Phoenix
Online08-2024
Bachelor of Science -
University of Phoenix
Online, AL07.2023
Management & Supervisory Development -
Columbus Technical College
Columbus, GA01.2006
References
Available upon request
Timeline
Compliance Manager
Elevance Health
01.2023 - Current
Regulatory Compliance Consultant
Elevance Health
01.2022 - 01.2023
Compliance Consultant
Anthem
01.2021 - 01.2022
Performance Quality Analyst II - MTM
Anthem
02.2015 - 02.2021
Graduate Certificate - Health Care Compliance And Privacy
University of Phoenix
Bachelor of Science -
University of Phoenix
Management & Supervisory Development -
Columbus Technical College
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