SAP
Evangelina Davis
Flushing,NY
Overview
25
25
years of professional experience
6
6
years of post-secondary education
Work History
Compliance Analyst Auditor
Optum
11.2023 - 03.2025
- Company Overview: Optum, Inc. is an American pharmacy benefit manager and health care provider. It is a subsidiary of UnitedHealth Group since 2011.UHG formed Optum by merging its existing pharmacy and care delivery services into the single Optum brand, comprising three main businesses: OptumHealth, OptumInsight and OptumRx
- Demonstrated understanding of the impact of applicable state and federal law regulations, mandates and contracts on our business and operations, including custom specific state laws.
- Collaborated with applicable internal partners to help interpret and apply laws e.g. Legal and business owners, business leaders, product owners, business operations, board members, regulations, and contracts appropriately within specific business settings.
- Monitored change to laws and regulations to ensure compliance with State and Federal Laws, regulations, and mandates.
- Conducted state specific legal research and monitor changes to requirements to mitigate risks and achieve compliance.
- Develop compliance communications and drive problem resolutions for a business segment.
- Conducted monthly audits of OIG/SAM checks, UM denial, Paid Claims (clean), Grievance and appeal, Pre-authorizations files for all UM accounts to identify compliance with NCQA, CMS and federal regulations along with contract requirements.
- Gathered and maintained compliance-related data from applicable systems/databases for use in reporting/communications and audits.
- Developed open lines of communication with all relevant stakeholders to confirm their buy-in and understanding of compliance and associated risk.
- Conducted internal monitoring/auditing to identify process gaps and help the business address organizational risks.
- Analyze results of audits and monitoring processes to identify potential risks and communicate as needed.
- Collaborate with internal stakeholders across organizational lines to help identify root causes of compliance issues, and support appropriate action to mitigate risk, as needed.
- Identified and communicated compliance status and issues to applicable audiences (e.g. Business leaders, product owners, business operations, CEO).
- Developed and updated compliance scorecards/reports, and communicate to applicable stakeholders during compliance committee meetings.
- Optum, Inc. is an American pharmacy benefit manager and health care provider. It is a subsidiary of UnitedHealth Group since 2011.UHG formed Optum by merging its existing pharmacy and care delivery services into the single Optum brand, comprising three main businesses: OptumHealth, OptumInsight and OptumRx
Compliance Analyst Auditor
United HealthGroup, INC. D/B/A MCNA
11.2022 - 11.2023
- Company Overview: MCNA Dental is one of the largest dental insurers in the nation for government-sponsored Medicaid and CHIP programs. They have been in business for over 30 years and serve millions of children and adults who trust their smiles to MCNA
- Identified compliance contacts/stakeholders to drive compliance program implementation within the business (e.g. compliance committee, oversight structure, business process owners).
- Collaborate with applicable stakeholders to promote adherence to compliance programs among employees within their scope of influence.
- Develop/implement/facilitate compliance standards, policies, procedures and codes of conduct.
- Develop, implement, facilitate auditing/monitoring processes to identify program issues and help the business address them.
- Collaborate with internal/external business partners to help develop and implement effective fraud and abuse detection and reporting programs.
- Respond to reported compliance issues and develop/facilitate corrective actions as necessary.
- Identify industry best practices for compliance programs to determine how our organization compares to other organizations in applicable markets, and identify opportunities for improvement.
- Conducted quarterly compliance committee meetings amongst key stakeholders.
- MCNA Dental is one of the largest dental insurers in the nation for government-sponsored Medicaid and CHIP programs. They have been in business for over 30 years and serve millions of children and adults who trust their smiles to MCNA
Compliance Analyst Auditor
Optum
01.2021 - 11.2022
- Company Overview: Optum, Inc. is an American pharmacy benefit manager and health care provider. It is a subsidiary of UnitedHealth Group since 2011.UHG formed Optum by merging its existing pharmacy and care delivery services into the single Optum brand, comprising three main businesses: OptumHealth, OptumInsight and OptumRx
- Demonstrated understanding of the impact of applicable state and federal law regulations.
- Responsible for regulatory compliance process and audits.
- Monitored change to laws and regulations to ensure compliance with State and Federal Laws, regulations, and mandates.
- Conducted state specific legal research and monitor changes to requirements to mitigate risks and achieve compliance.
- Develop compliance communications and drive problem resolutions for a business segment.
- Respond to reported compliance issues and develop/facilitate corrective actions as necessary.
- Collaborate with applicable internal partners to help interpret and apply laws, regulations, and contracts appropriately within specific business settings.
- Collaborated with applicable regulators (e.g., CMS, NCQA) to help appropriately interpret applicable mandates/regulations for the organization as appropriate.
- Create Emerging Risks and Regulatory trends report that is emailed to leaders monthly by research and reading materials from different websites such as OIG, Kaiser News, Becker, Healthcare Dive, Radical Compliance.
- Optum, Inc. is an American pharmacy benefit manager and health care provider. It is a subsidiary of UnitedHealth Group since 2011.UHG formed Optum by merging its existing pharmacy and care delivery services into the single Optum brand, comprising three main businesses: OptumHealth, OptumInsight and OptumRx
Regulatory Compliance Auditor
Orthonet
06.2018 - 01.2021
- Company Overview: Orthonet was the leading orthopedic specialty benefit management company in the United States which has since been acquired by Optum.
- Conducted monthly audits of UM denial and appeal files for all UM accounts to identify compliance with NCQA, CMS and federal regulations along with contract requirements.
- Analyzed results by client and by standards to identify trends and/or adverse findings.
- Summarized results in a report and shared with the Operational areas for investigation of root causes and implementation of corrections.
- Collected root Causes and corrective action documentation from teams and maintains all required documentation in Audit Department repository.
- Escalated compliance concerns to Audit department leadership, as applicable and presented audit results for discussion at various OrthoNet Committees as needed.
- Utilizing data reports, system verification methods, and monitoring reports, identified potential operational deficiencies.
- Designed management reports which summarized monitoring activities, results and corrections taken and contributed to methodology and reporting mechanism for Internal Audit.
- Orthonet was the leading orthopedic specialty benefit management company in the United States which has since been acquired by Optum.
Care Specialist
EmblemHealth
06.2014 - 05.2018
- Company Overview: EmblemHealth is a New York Insurance company that began with ideals rooted in a simple, yet pioneering vision: provide quality health insurance plans for working New Yorker and their families.
- Generated client letters in MAXMC such as 'Call Me', 'HIPAA' and 'Member Introduction' letters to members.
- Created Desktop Job Aides according to Emblemhealth’s Operational process.
- Created and interpreted spreadsheets for the Case Management department for daily activities and reporting purposes.
- Utilized ESAWS as a resource tool for verifying members who contacted Emblem via the telephone.
- Referred members from LTSS, SNP MOD, SNP HRA to various nurses through the MAXMC referral system.
- Utilized CareSync for referrals, troubleshooting and verifying programs members were assigned to.
- Assisted with Compliance Auditing and support for other internal departments such as Utilization Management, Disease Management, Care Management, Diabetes Management etc.
- Triaged telephone calls from members who were in the path program and referred members to the Disease Management nurses.
- Maintained TOC program spreadsheet for reporting and inaccuracies, reporting daily and monthly numbers to management.
- Maintained LACE report for TOC members and shared it amongst the Care Management team.
- Addressed any returned mailings for incorrect addresses that was returned by the post office.
- Assisted with various projects as assigned by management.
- EmblemHealth is a New York Insurance company that began with ideals rooted in a simple, yet pioneering vision: provide quality health insurance plans for working New Yorker and their families.
Operations Analyst (Team Leader)
Healthfirst NY
09.2013 - 04.2015
- Company Overview: Healthfirst is a privately owned insurance company in the Metropolitan area that provides low cost or free high quality medical and dental insurance to individuals and families through government programs. The company was established in 1993 and has over one million members and a network of 24,000 providers.
- Evaluated account receivable reports and analyzed revenues and payment trends.
- Processed government sponsored Obamacare QHP and CHP invoice billing in our PowerMHS billing system.
- Generated CHP and QHP Disenrollment, Reinstatement and Dunning monthly to our new and ongoing members.
- Generated AR Commentary and Deferred Revenue to ensure the members that were delinquent on the previous month are no longer outstanding and reporting my findings to management.
- Structured and implemented the Accounts Receivable department by creating Team Assignments and Job Aides for each task.
- Was appointed Team Lead within the AR department and trained new hires and re-trained employees as needed in New York and Florida.
- Answered customer inquiries through our Macess system.
- Assisted Management in various projects such as Revamping of our Lockbox and Authorize.Net processes.
- Devised the universal codes for Posting batches within our system to members accounts for accurate reporting to Management.
- Assigned as SME and UAT person to affiliate new processes and procedures.
- Healthfirst is a privately owned insurance company in the Metropolitan area that provides low cost or free high quality medical and dental insurance to individuals and families through government programs. The company was established in 1993 and has over one million members and a network of 24,000 providers.
Accounts Analyst
New York Healthcare
09.2012 - 09.2013
- Company Overview: New York Healthcare is a privately owned certified Short- and Long-Term home health aide agency offering personal care and HHA care to patients that are not capable of taking care of themselves on their own.
- Ensures all invoicing is billed daily for all LTHHCP’S, CHHA’s, MLT’s and MLTC’s in accordance with company practices and client contract agreements and perform any follow-up on provider bills not received in a timely manner to decrease invoicing delays.
- Contacts LTHHCP, MLT, MLTC and CHHA vendors to resolve any invoice problems or discrepancies and if necessary, makes additional contact with clients for the collection of outstanding invoicing.
- Research and responds to inquiries from vendors such as Eisep, Elant, Personal Touch, Beth Abe, VNS, CNR, Montifiore, Morningside, Jewish Home Health Care, Guildnet, Homefirst, Amerigroup, Independence Care system etc., regarding payment issues and invoice.
- Ensures the confidentiality and security of all financial files according to HIPAA.
- Utilized Sandata, HHA Exchange and Healthwyse systems to verify payroll data.
- Trained Management and new hires on operating systems.
- Key 'go to' person for resolving issues with billing on all contracts.
- Assist Management with projects.
- Conducts systematic review of all aging accounts over 30 days and contacts clients regarding the collection of outstanding accounts.
- Prints and mails current and/or past due invoices along with their prospective duty sheets as needed.
- New York Healthcare is a privately owned certified Short- and Long-Term home health aide agency offering personal care and HHA care to patients that are not capable of taking care of themselves on their own.
Senior Billing/Payroll/Accounts Receivable Specialist
Renaissance Home Health Care
01.2010 - 09.2012
- Company Overview: Renaissance Home Healthcare is a privately owned certified Short and Long Term home health aide agency offering personal care and HHA care to patients that are not capable of taking care of themselves on their own.
- Verify payroll data via the HCPLUS scheduling system, HHA Exchange and paper duty sheets daily.
- Investigated and resolve all discrepancies identified on the HK report, Unverified report, and Billing Edit Reference Report.
- Daily interactions with the coordinators to resolve time sheets discrepancies and entering personal tasks.
- Audit service authorizations and schedules to ensure payroll can close smoothly which consists of contacting vendors if needed.
- Report weekly sales and hours on excel spreadsheet to upper management.
- Assist Team leader in coordinating all activities to ensure payroll is generated within a timely matter on a weekly basis.
- Enter Time slips into Prohealth for Invoicing.
- Prepared Personnel Touch batch spreadsheet for invoices to be overnighted to the vendor.
- Match invoices to required electronic duty sheets and paper duty sheet and send to appropriate account for payment.
- Assist with sending electronic (EDI) billings to contractors i.e., Guildnet, Homefirst, Metropolitan Jewish and First to Care.
- Posted checks weekly within the Prohealth system and identify discrepancies to be addressed later after posting.
- Processed all adjustments, credits, debits, and voids.
- Generate Cash Receipts and Sales Journals for designated staff within the company.
- Ran aging reports to identify skipped payments, partial payments, or non-payments.
- Resolved all discrepancies received from vendors.
- Implemented and started the Accounts receivables structure in the Finance Dept.
- Renaissance Home Healthcare is a privately owned certified Short and Long Term home health aide agency offering personal care and HHA care to patients that are not capable of taking care of themselves on their own.
Credit Relations Manager/Account Specialist
Harman Consumer Group
05.2000 - 05.2009
- Company Overview: Harman Consumer group is a leading electronics company in the industry. Harman Consumer Group is the parent company behind an array of legendary brands that includes Harman Kardon, JBL, Mark Levinson, AKG and Infinity Systems. We are a leading global provider of premium audio and infotainment solutions engaging customers around the home in the car and on the go.
- Responsible for credit hold within territory (releasing and calling on past due invoices to expedite pending orders).
- Reconciling accounts to properly maintain current A/R status.
- Responsible for providing written correspondence/reporting to dealers, sales force, and upper management.
- Daily contact with internal and external customers.
- Manage and maintain all accounts for all brands per territory assigned which includes collection calls, maintaining orders (pricing, quantities, returns, infield destroy, requests, etc.).
- Create credit/debit memo requests and return authorizations.
- Work with manager regarding all functions pertaining to Sales and operations.
- Interacted closely with dealers, Sales Marketing and Logistics.
- Maintain DSO to maximize cash flows and meet collection goals for monthly targets.
- Maintain Bad Debt and interact in weekly meetings to network problem solving.
- Harman Consumer group is a leading electronics company in the industry. Harman Consumer Group is the parent company behind an array of legendary brands that includes Harman Kardon, JBL, Mark Levinson, AKG and Infinity Systems. We are a leading global provider of premium audio and infotainment solutions engaging customers around the home in the car and on the go.
Summary
Quality-driven Compliance Analyst familiar with tracking, documentation and reporting requirements. Assesses work, materials and procedures and recommends adjustments to maintain compliance. Over 10 years of experience and motivated, energetic mindset.
Education
Bachelor of Science - Accounting
York College
Jamaica, NY 06.2011 - 01.2017
Skills
- Documentation review
- Research proficiency
- Compliance monitoring
- Internal auditing
Accomplishments
- Achieved 100% results by completing compliance audits with accuracy and efficiency.
- Collaborated with team of 8 in the development of moving files to Sharepoint.
- Documented and resolved non-compliance which led to 100% results from external auditors.
- Used Microsoft Excel to develop inventory tracking spreadsheets.
- Resolved product issue through consumer testing.
Work Availability
monday
tuesday
wednesday
thursday
friday
saturday
sunday
morning
afternoon
evening
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Work Preference
Work Type
Full TimeWork Location
On-SiteRemoteHybridImportant To Me
Career advancementPersonal development programsCompany CultureQuote
There is a powerful driving force inside every human being that, once unleashed, can make any vision, dream, or desire a reality.
Tony Robbins
Software
Microsoft Office Suite
Sharepoint
Macess
Tableau
Power DMS
Power BI
HHA Exchange
ECAA User Acceptance Testing
Data Mining
EPACES
Emdeon
EDI
EGRC
DentalTrac
Looker
Teams
PowerMHS
ICUE
Languages
English
Full Professional
Timeline
Compliance Analyst Auditor
Optum
11.2023 - 03.2025
Compliance Analyst Auditor
United HealthGroup, INC. D/B/A MCNA
11.2022 - 11.2023
Compliance Analyst Auditor
Optum
01.2021 - 11.2022
Regulatory Compliance Auditor
Orthonet
06.2018 - 01.2021
Care Specialist
EmblemHealth
06.2014 - 05.2018
Operations Analyst (Team Leader)
Healthfirst NY
09.2013 - 04.2015
Accounts Analyst
New York Healthcare
09.2012 - 09.2013
Bachelor of Science - Accounting
York College
06.2011 - 01.2017
Senior Billing/Payroll/Accounts Receivable Specialist
Renaissance Home Health Care
01.2010 - 09.2012
Credit Relations Manager/Account Specialist
Harman Consumer Group
05.2000 - 05.2009
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