Cheryl Macdougall
Collegeville,PA
Summary
HEALTHCARE AUDIT & COMPLIANCE PROFESSIONAL implementing processes, systems, and programs that drive continuous improvement. 15+ years developing innovative yet pragmatic processes, strategies and tools which improve and ensure compliance. Skilled project manager using Lean Six Sigma to optimize operations and reduce risk. Proactively maintains knowledge of rapidly evolving state and federal laws, requirements and industry standards. Able to command entire audit process including reviewing procedures, documentation and systems; collaborating with cross-departmental stakeholders; and remediating weaknesses and deficiencies. Background includes devising training programs that instill a culture of compliance at all levels of the organization. Known for promoting excellence organization-wide through motivation, training, empowerment, and personal example.
Overview
25
25
years of professional experience
2
2
Certification
Work History
Manager, Payment Integrity
Independence Blue Cross
01.2018 - Current
- Provide expertise in payment accuracy, and project management to identify the overpayment of professional, and institutional and ancillary service claims associated with provider billing and claim system processing errors
- Manage team of 13 auditors and analysts and 6 audit vendors to identify overpayments and resolve claim adjudication issues
- Responsible for a recovery budget of $60M.
Director, Audit Operations
Cotiviti Healthcare, Inc.
01.2015 - 01.2017
- Provided expertise in payment integrity, and project management to ensure successful delivery of audit services to clients in the healthcare industry
- Focus on continuous improvement, innovative solutions, and concept development to optimize the audit process in 5 assigned client accounts (payers' plans)
- Develop processes, systems, and controls
- Manage overpayment budget of $93M.
Director, Revenue Operations, Government Payer Relations
DaVita Healthcare Partners, Inc.
01.2010 - 01.2015
- Developed insurance requirements including details of third-party commercial, contract, government and managed care plan reimbursement
- Established and maintained cooperative relationships with Medicare contractors and Medicaid agencies to optimize operations and reimbursement.
Director, Audit and Compliance
DaVita Healthcare Partners, Inc.
01.2000 - 01.2010
- Coordinated enterprise-wide audit and compliance program, establishing formal structure, processes, and systems to ensure full federal, state, and local compliance
- Coordinated internal and external audits as primary point of contact throughout audit and remediation.
Education
Master of Business Administration - Project Management
St. Joseph's University
Bachelor of Science - Finance
Jefferson (Philadelphia) University
Philadelphia, PASkills
- Regulatory Compliance
- Corporate Integrity
- Revenue Cycle Management
- Internal / External Audit
- Policy & Process Development
- Complex Problem-Solving
- Project Management
- Relationship-Building
- Verbal and Written Communication
- Team Leadership & Development
- Cross-Functional Teamwork
Certification
- Lean Six Sigma Certification, Villanova University
- Paralegal Certification: Corporate Finance & Business Law, Philadelphia Institute of Paralegal Training
Timeline
Manager, Payment Integrity
Independence Blue Cross
01.2018 - Current
Director, Audit Operations
Cotiviti Healthcare, Inc.
01.2015 - 01.2017
Director, Revenue Operations, Government Payer Relations
DaVita Healthcare Partners, Inc.
01.2010 - 01.2015
Director, Audit and Compliance
DaVita Healthcare Partners, Inc.
01.2000 - 01.2010
- Lean Six Sigma Certification, Villanova University
- Paralegal Certification: Corporate Finance & Business Law, Philadelphia Institute of Paralegal Training
Master of Business Administration - Project Management
St. Joseph's University
Bachelor of Science - Finance
Jefferson (Philadelphia) University
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