Matthew Colom
Hialeah
Summary
Experienced Compliance/Quality Analyst with 9 plus years of experience in the Medicare (CMS), Insurance and Healthcare field. Compliance professional focused on improving compliance within the organization, workflow and processes through detailed audits, reporting and optimization while maintaining high standard in regulatory requests. Successful track record of of fully evaluating data, policies and procedures and initiating corrective actions.
Overview
9
9
years of professional experience
Work History
Quality Assurance Analyst-Team Lead
MMM Of Florida
Miami, FL
12.2020 - 12.2023
- Established metrics, applied industry best practices and developed new tools and processes.
- Medicare Compliance/Memos.
- Financial Information Reporting (FIR)/Prescription Drug Events (PDE) error corrections.
- Performed audits on Part D and B Cases/Coverage Determinations/DMR.
- Part D claims analysis.
- Performed LICS, Hospice and ESRD claims analysis.
- Reassessed quality control measures at systemic level to proactively identify non-conformances.
- Oversight of various Part D processes.
- Acted as key point of contact for all QA aspects of releases by providing QA services and coordinating QA resources internally and externally.
- Conducted evaluations to identify weak areas and identify problematic issues while promoting corrective methods.
- CAPS.
- Marketing Materials.
- Worked closely with PBM (Pharmacy Benefits Manager) for oversight of department processes
- Monitored activities and supporting systems to meet compliance regulations.
- Supported company in maintaining work environment focused on quality, communication, collaboration, integration, and teamwork.
- Mentored and coached team members on QA topics and strategies.
Compliance Investigator
Assurance IQ-Prudential
Seattle, WA
01.2019 - 12.2020
- Conducted agent investigations and prepared detailed reports with facts and findings.
- Worked closely with different lines of insurance Territory Managers including Health-U65, Life, and Medicare to report agent activity.
- Collaborated with Compliance QA analysts and assisted with audits, call audits, and complaints (Internal complaints, escalated complaints and DOI complaints).
- Was responsible for monthly reporting of Complaints metrics and presenting to Chief Compliance officer and executives.
- Completed complaint intake forms and handled agent disciplinary actions.
- Performed various audits and team calibrations.
- Provided and created internal team trainings.
- Pulled reports for extraction of readable data.
- Worked extensively with Data Science for data required on reports.
- Familiarity with Medicare AEP, OEP, IEP and SEP election periods.
- Confirmed data and licensing information through investigations and notified violators of required changes to bring operations into compliance.
- Reviewed compliance laws and updated investigation strategies to reflect current information.
- Collected detailed notes on investigations and other communication to adhere to legal requirements and enhance recordkeeping.
- Handled internal and external allegations.
- Reviewed, documented and investigated allegations of suspected wrongdoing.
- Researched issues and laws related to investigations.
- Worked with designated third-party vendors to input information and verify regulatory compliance.
- Enforced compliance with complex state and federal laws, rules and regulations for industry.
- Developed and implemented corrective action plans for non-compliance issues.
Compliance Analyst
Anthem
01.2015 - 12.2018
- Researched and updated policies and procedures.
- Planned and presented meetings on compliance updates from CMS.
- Took involvement in CMS audits and mock audits for upcoming audits from Medicare.
- Created and maintained detailed reports of discrepant findings for compliance.
- Resolved PDE (Prescription Drug Events) errors.
- Worked closely with PBM for department oversight of processes.
- Lead department to earn 5 Star Rating from Medicare
- Prepared documentation and records for upcoming audits and inspections.
- Was responsible for actionable CMS Memos and timely correction/update of current process.
- Reviewed marketing materials for compliance.
- Corrected Financial Information Reporting (FIR) errors.
Auditor/Call Auditor
Anthem
- Performed Compliance internal audits for Medicare Part D.
- Reported investigative findings of discrepant practices to management for corrective action to maintain compliance as per CMS guidelines.
- Conducted audits of the healthplan's member Part D calls involving member coverage determinations, Appeals and Grievances and Reimbursements.
- Identified and analyzed data between Coverage Determinations and Appeals and Grievances (CDAG).
- Ensured proper documentation and resolution was provided to all calls from member's and other sources.
- Conducted investigations in relations to (FWA) Fraud Waste & Abuse.
- Planned and executed audits; collected, verified audit evidence, composed findings and conclusions, assisting in preparation for CMS and compliance audits.
- Summarized findings and recommendations with Part D Coordinators within the department and presented to management.
- Followed established auditing processes to meet internal and regulatory requirements.
- Analyzed data and findings to prepare reports detailing financial information.
Education
Bachelors Business Administration -
Florida Atlantic University
Boca Raton, FL08.2005
AA - Business Admin
Broward College
Hollywood, FL02.2002
Skills
- Regulatory Compliance
- Data Analysis
- Reporting
- Investigation Facts & Findings
- CMS
- Audit Preparation
- Discrepancy Reconciliation
- Policy and Procedure oversight
- Financial Reporting
- Claim Data Analysis
- Financial Management
- Audit Plan Development
- SOP Adherence
- Process Evaluations
- Marketing Material
- Insurance
Timeline
Quality Assurance Analyst-Team Lead
MMM Of Florida
12.2020 - 12.2023
Compliance Investigator
Assurance IQ-Prudential
01.2019 - 12.2020
Compliance Analyst
Anthem
01.2015 - 12.2018
Auditor/Call Auditor
Anthem
Bachelors Business Administration -
Florida Atlantic University
AA - Business Admin
Broward College