Carolyn Griego
Rio Rancho,NM
Summary
Healthcare compliance executive with 21+ years of experience in Medicaid regulatory compliance, contract oversight, and risk management. Expertise in strategic planning, audit management, and operational efficiency, ensuring compliance excellence while optimizing business performance. Proven ability to advise senior leadership, collaborate with state and federal regulators, and lead enterprise-wide initiatives to drive quality, patient safety, and organizational integrity.
Skilled in policy development, corrective action planning, and risk mitigation, ensuring full regulatory adherence and financial oversight. Adept at cross-functional collaboration, data-driven decision-making, and executive stakeholder engagement, influencing Medicaid policy changes, contract execution strategies, and enterprise compliance frameworks. Dedicated to enhancing Medicaid program administration through compliance training, regulatory reporting, and strategic partnerships to drive long-term success.
Overview
21
21
years of professional experience
Work History
Director, Compliance
Western Sky Community Care
09.2018 - 08.2024
- Acted as the Medicaid Contract Manager and liaison to the New Mexico Human Services Department (HSD), Medicaid Assistance Division (MAD), Behavioral Health Services Division (BHSD), Long-Term Services and Supports (LTSS) Bureau, and other State and Federal government entities, ensuring compliance and supporting strategic objectives.
- Developed and implemented enterprise-wide strategic planning roadmaps to align Medicaid compliance operations with state and federal priorities.
- Directed high-impact Medicaid projects and initiatives, including Letter of Direction implementation, contract amendments, and policy changes, successfully achieving a 90-95% implementation rate within state-directed deadlines.
- Spearheaded the submission of over 500 regulatory reports annually on various schedules (monthly, quarterly, semi-annual, annual, and ad-hoc), achieving a 100% track record in timely submissions.
- Directed all compliance audits issued by State regulators and external stakeholders, ensuring meticulous preparation, execution, and follow-up, resulting in consistent regulatory compliance and enhanced patient safety.
- Oversaw the timely submission and compliance of all operational deliverables across business lines, ensuring adherence to State and Federal agency requirements with a 90% success rate in timeliness and accuracy.
- Mitigated risks and implemented corrective action plans proactively based on audit findings and contract assessments, ensuring continuous compliance and operational efficiency.
- Monitored contractual monetary penalties, processed rebuttals on penalties, and managed departmental budget costs to optimize financial oversight.
- Championed the development and implementation of the annual compliance work plan, fraud program, and risk assessment to enhance compliance and mitigate risks.
- Developed and implemented policies and procedures in strict accordance with the Medicaid contract, ensuring comprehensive compliance and operational efficiency.
- Synthesized complex regulatory releases into actionable insights and communicated findings to senior leaders, facilitating timely and effective compliance measures.
- Established and optimized tracking and monitoring dashboards, driving a 25% increase in audit efficiency and a 20% reduction in compliance-related errors.
- Achieved outstanding full compliance review ratings between 94% and 99% from 2019 to 2023.
- Managed vendor relationships by engaging in policy requirement discussions, updating contracts to ensure compliance, negotiating terms, and implementing penalties for non-compliance.
- Led cross-functional collaboration across multiple departments, including Compliance, Finance, Operations, Call Center, Pharmacy, Provider Relations, Marketing, Care Coordination, Contracting, IT, and Data & Analytics, ensuring seamless Medicaid contract execution aligned with business strategy.
- Drove process improvements through the use of tracking tools to monitor compliance, ensuring transparency with state regulators on amendment implementation. Participated in regulatory workgroups to collaboratively address and resolve challenges.
- Participated in weekly meetings with state contract managers, offering strategic policy amendment suggestions that benefited organizational objectives and influenced state regulatory decisions positively.
- Collaborated with analytics teams on data scrubbing and SQL queries to support decision-making processes, enhancing the accuracy and integrity of reported data.
- Conducted quarterly training activities on compliance, fraud programs, new laws, regulations, and state reporting requirements, resulting in increased staff compliance knowledge.
- Supervised compliance for marketing materials, ensuring thorough reviews and alignment with contractual and regulatory requirements.
- Collaborated with marketing on system enhancements to ensure product benefits were aligned with contracting requirements.
- Managed the translation and certification process, submitting the certificate of accuracy to the state for final approval.
- Managed the communication and resolution process for suspected fraud within the health plan, ensuring accurate and credible reporting.
- Collaborated with management to address non-compliance issues, ensuring adherence to regulatory standards and enhancing overall compliance.
- Fostered and maintained positive, professional relationships with State agencies and external stakeholders to ensure effective communication and reporting.
- Led Compliance Committee initiatives, collaborating with executive leadership to develop enterprise-wide compliance policies and risk mitigation strategies.
- Strategically advised senior leadership on Medicaid contract changes, ensuring organizational alignment with evolving regulations and regulatory compliance priorities.
- Led staff to achieve departmental goals, mentoring them to become subject matter experts in their respective product lines, enhancing the team's overall performance and productivity by 30%.
- Developed succession planning, coaching, and performance management frameworks, ensuring team members were prepared for leadership roles.
- Served as a member of the Compliance Committee, routinely presenting data-driven reports, strategic recommendations, and policy changes to executive leadership.
- Enhanced member engagement by 15% through strategic leadership of Member Advisory Boards and facilitated outreach initiatives led by the Ombudsman, improving communication and feedback mechanisms to enhance patient safety and quality of care.
- Oversaw the seamless unwinding of all compliance and reporting activities as outlined in the contract.
Director, Government Contracts
Molina Healthcare, Inc.
01.2017 - 08.2018
- Acted as the Medicaid Contract Manager and liaison to the New Mexico Human Services Department (HSD), Medicaid Assistance Division (MAD), Behavioral Health Services Division (BHSD), Long-Term Services and Supports (LTSS) Bureau, and other State and Federal government entities, ensuring compliance and supporting strategic objectives.
- Coordinated, reviewed, and submitted operational deliverables across all business lines as required by State and Federal agencies, achieving exceptional timeliness and accuracy with a 100% submission rate.
- Directed comprehensive audit control activities, executing mock audits for system-wide audits issued by State regulators, External Stakeholders, and Corporate Compliance, ensuring thorough preparation and compliance with a 100% success rate while promoting high standards of patient safety.
- Managed corrective action plans and remediation based on internal and external audits, fostering cross-departmental collaboration to ensure timely completion and adherence to regulatory requirements, thereby enhancing quality of care.
- Addressed contractual and regulatory concerns issued by state and federal agencies, maintaining compliance and mitigating risks proactively.
- Conducted rigorous impact assessments on proposed State and Federal laws and regulations, analyzing their potential effects on operations, finance, and network areas.
- Facilitated comprehensive training activities and education on a quarterly and ad-hoc basis, as required by the Medicaid contract, including compliance and fraud programs, new laws, regulations, and state reporting requirements.
- Monitored and tracked the health plan's compliance with State and Federal regulatory standards, ensuring unwavering adherence to all requirements and contributing to overall quality of care.
- Oversaw contractual sanctions for reporting, ensuring timely and accurate compliance.
- Led cross-functional collaboration to ensure all contractual requirements and program initiatives were met, driving cohesive and compliant operations.
- Guided departmental staff in achieving assigned goals and job duties, mentoring them to excel and contribute to departmental success.
- Successfully assisted in the seamless unwinding activities of the Medicaid contract, ensuring all final compliance obligations were met with precision.
Manager, Behavioral Health Government Contracts
Molina Healthcare, Inc.
09.2014 - 12.2016
- Acted as the Behavioral Health Medicaid Contract Manager and primary liaison to the New Mexico Human Services Department (HSD), Medicaid Assistance Division (MAD), Behavioral Health Services Division (BHSD), and other State and Federal regulatory agencies, ensuring full compliance with contractual and policy requirements while supporting enterprise-wide strategic objectives.
- Developed and maintained strategic relationships with state regulators, positioning the health plan as a trusted leader in Behavioral Health policy development. Successfully led state-directed workgroups, shaping regulatory discussions and enhancing organizational influence in Medicaid policy decisions.
- Directed comprehensive oversight of all contractual behavioral health reporting and deliverables, maintaining 100% compliance with state and federal Medicaid regulations while improving audit readiness and operational efficiency.
- Led regulatory compliance monitoring across the health plan, ensuring full alignment with federal and state contractual obligations while driving proactive risk mitigation and patient safety enhancements.
- Oversaw the implementation, monitoring, and resolution of Corrective Action Plans (CAPs) issued by state agencies, ensuring timely remediation, compliance adherence, and quality improvement through cross-functional collaboration.
Compliance Specialist
Molina Healthcare, Inc.
04.2013 - 09.2014
- Conducted comprehensive compliance reviews and audits, identifying and mitigating potential risks, ensuring 100% regulatory adherence and enhancing patient safety.
- Monitored and reported on critical compliance metrics, providing data-driven insights to support compliance oversight and leadership decision-making.
- Assisted in the strategic oversight of compliance activities, ensuring adherence to state and federal regulations.
- Developed and implemented compliance training programs, increasing staff compliance knowledge by 30%, ensuring regulatory requirements were met, and improving overall quality of care.
- Collaborated seamlessly with cross-functional teams, successfully resolving 100% of identified compliance issues through corrective action plans and ensuring long-term compliance sustainability.
Director of Facility Training
Desert Hills, Youth and Family Centered Services
12.2003 - 04.2013
- Served as a key member of the Senior Management Team, contributing to strategic decision-making, regulatory compliance initiatives, and workforce development strategies.
- Spearheaded the development and execution of enterprise-wide training programs, conducting bi-weekly staff development trainings with an average of 20 participants to enhance compliance and operational efficiency.
- Improved quality of care and patient safety by managing incident reports, increasing incident report submission rates, and reducing questionable restraints and seclusion's by 15%.
- Led New Employee Orientation (NEO) and staff development programs, ensuring strict regulatory compliance and improving workforce readiness.
- Conducted mock surveys for Joint Commission accreditation, strengthening audit preparedness and adherence to regulatory standards.
- Designed and implemented cost-effective training curricula focused on therapeutic milieu and proper restraint techniques, fostering a safe and supportive care environment.
- Strategically collaborated with senior management to drive continuous learning initiatives, ensuring compliance, professional development, and high-quality service delivery.
Education
Master of Business Administration (MBA) - Healthcare Administration
New Mexico Highlands University
Las Vegas, NM12-2024
Bachelor of Science - Human Service Management
University of Phoenix
Albuquerque, NM01.2008
Skills
- Strategic Program Management
- Regulatory Compliance
- Risk Management
- Financial & Operational Oversight
- Stakeholder & Relationship Management
- Change Management
- Process Improvement
- Leadership & Team Development
- Data Analysis & Reporting
- Healthcare Industry Expertise
Timeline
Director, Compliance
Western Sky Community Care
09.2018 - 08.2024
Director, Government Contracts
Molina Healthcare, Inc.
01.2017 - 08.2018
Manager, Behavioral Health Government Contracts
Molina Healthcare, Inc.
09.2014 - 12.2016
Compliance Specialist
Molina Healthcare, Inc.
04.2013 - 09.2014
Director of Facility Training
Desert Hills, Youth and Family Centered Services
12.2003 - 04.2013
Bachelor of Science - Human Service Management
University of Phoenix
Master of Business Administration (MBA) - Healthcare Administration
New Mexico Highlands University
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