LINETTE HUGHES
Sacramento,CA
Summary
Over 10 years of managed healthcare experience implementing computer systems, developing processes, managing staff and gaining the respect and trust among all staff and clients. Building great relationships are key to many of my successes. I am an inclusive leader and I value the perspective and ideas of others. Being an inclusive leader has resulted in many positive impacts to business operations such as improved quality controls and financial sustainability.
Overview
11
11
years of professional experience
2
2
Certifications
Work History
Chief Compliance and Privacy Officer
Nivano Physicians
08.2018 - Current
- Reduced Corrective Action Plans by 30%
- Lead and oversee the company Compliance Program for over 150,000 members and 7 Health Plan contracts
- Perform risk assessments and prioritize results
- Maintained up-to-date knowledge of current and emerging compliance regulations
- Develop, create, and maintain the Compliance department structure
- Chairman of the Compliance Committee
- Develop and oversee the Fraud, Waste, and Abuse processes
- Create training materials, educate and train the staff and contracted providers on compliance procedures
- Create and maintain Compliance and Privacy Policies and Procedures
- Oversee and investigate potential compliance issues and risks from our compliance hotline
- Responded to employee inquiries regarding compliance regulations and procedures
- Complete annual Compliance audits with our 7 contracted Health Plans
- Monitored and assessed compliance risks associated with operational processes and procedures
- Prepare and present Compliance updates quarterly to the Board of Directors
- Oversee timeliness standards and regulations for Utilization Management, Claims, Capitation, Encounters, Quality, and Eligibility departments
- Project Management/Implementation of new processes, software, contracts, programs, and strategies
- Coordinate the establishment of more efficient process for all departments, while ensuring complete staff work in all phases of operations
- Identified, investigated and documented compliance violations and recommended corrective measures
- Collaborated with internal and external stakeholders, auditors and legal counsel to confirm compliance with applicable laws and regulations
Implementation and Training Specialist
MedVision
04.2018 - 08.2018
- Implement medical insurance software to new clients
- Assist clients with identifying gaps in current policies and processes
- Assessed additional needs based on training progress and collaborated with management to meet requirements
- Project manager for new implementations
- Train client staff on the system capabilities and how to efficiently complete their job duties
- Train client’s external users on how to gather information to meet organizational needs
- Implement new polices and overall process improvement
- Determine and train clients on more efficient processes
Business Improvement Analyst
River City Medical Group
05.2012 - 04.2018
- Review and ensure claims compliance standards are being met
- Assess current processes within the Claims department to identify defects / areas of improvement and recommend solutions
- Configure the system pricing for new provider contracts
- Build the Division of Financial Responsibility (DOFR) in the system
- Reduced claim processing errors by 27%
- Create all training materials for new and current employees within the Claims department
- Increased auto adjudication from 30% to 75% with a 2% error rate
- Analyze claims data to identify areas of improvement
- Build pivot tables and query models to perform business analysis
- Create reports, using SQL database, to identify errors within manual claim processing
- Configure auto adjudication rules to improve department efficiency within the Claims department
- Configure systematic claims pending edits to ensure claims were reviewed correctly by company Examiners
- Tested our software for all new upgrades to ensure proper performance
Education
MBA - Business Administration
University of Phoenix
01.2023
Bachelor of Science - Business
University of Phoenix
09.2017
Associate of Applied Science - Medical Office Administration
Heald College
04.2012
Skills
- Compliance & Privacy
- HIPAA & HITECH
- Process Improvement
- Problem Resolution
- Leadership
- Project Management
- Strategic Planning
- SQL Database
- Company Operations
- Critical Thinking
Certification
- Certified Healthcare Compliance (CHC), HCCA -September 2021
- Certified Healthcare Privacy Compliance (CHPC), HCCA - June 2023
Timeline
Chief Compliance and Privacy Officer
Nivano Physicians
08.2018 - Current
Implementation and Training Specialist
MedVision
04.2018 - 08.2018
Business Improvement Analyst
River City Medical Group
05.2012 - 04.2018
MBA - Business Administration
University of Phoenix
Bachelor of Science - Business
University of Phoenix
Associate of Applied Science - Medical Office Administration
Heald College
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