Melinda Vang
TX
Summary
Experienced Compliance Analyst with a demonstrated history of working in the healthcare industry. Skilled in regulatory compliance, gap analysis, policy development, and communication. Strong background in interpreting and implementing state and federal laws and regulations. Proven ability to conduct detailed analyses and testing to ensure compliance with applicable requirements. Excellent at collaborating with internal and external stakeholders to maintain positive communication and confidentiality. Compliance Analyst known for high productivity and efficiency in completing tasks. Specialized skills include regulatory compliance, risk management, and policy development. Excel at communication, problem-solving, and adaptability to ensure successful navigation through complex regulatory environments.
Overview
13
13
years of professional experience
Work History
Compliance Analyst II
Sutter Health Plus
Sacramento, CA
09.2017 - Current
- Collaborating with business operational leaders to review, analyze, and manage regulatory compliance project plans.
- Including conducting gap analyses, managing communications, and developing or revising policies, processes, and procedures.
- Act as a resource for state and federal regulatory requirements.
- Research new, pending, and amended laws and regulatory requirements that impact the health plan.
- Monitor and track proposed state legislation and federal regulations that affect the health plan.
- After legislation is enacted, provide details about the bills through presentations and written summaries, and assist with the implementation process to ensure compliance.
- Collaborate with operational leaders and legal and privacy sectors to address changes in state legislation and regulatory policies.
- Assist in preparing and coordinating regulatory audits, including collecting and thoroughly reviewing requested documents.
- Assist in responding to various requests for clarification or interpretation of these requirements, understanding the intent behind the questions, and performing necessary research and analysis to provide accurate responses and recommendations.
- Prepare and submit regulatory filings to the Department of Managed Healthcare to demonstrate implementation and compliance with newly enacted laws.
- Conduct detailed analyses and testing of policies, procedures, and workflows to ensure compliance with applicable state and federal regulatory requirements
- Support the Compliance Officer in proactively responding to actual or potential violations identified through routine auditing, monitoring, government inquiries, investigations, or reports submitted via the Confidential Message Line at the affiliate level
- Collect, analyze, trend, and report compliance data on high-risk areas and incidents related to fraud, waste, and abuse within the health plan
Operations Auditor
Sutter Health Plus
Sacramento, CA
01.2017 - 09.2017
- Led internal audits for Claims, Provider Resolution Disputes, Enrollment, and Premium Billing, ensuring strict compliance with Department of Management Healthcare regulations.
- Conducted over 2,000 external claims and provider disputes audits annually for Risk Bearing Organizations (RBOs), confirming adherence to top compliance standards.
- Developed and implemented over 20 innovative internal workflows and policies for the Claims, Provider Resolution Disputes, and Premium Billing departments, driving operational excellence.
- Proactively tracked audit findings to identify gaps, providing strategic feedback to team members to swiftly resolve issues.
- Delivered comprehensive quarterly and annual DMHC claims settlement and provider dispute reports, showcasing compliance and operational efficiency.
- Proven ability to manage multiple complex programs while understanding DMHC regulations and healthcare reimbursement models comprehensively.
Senior Quality Consultant
Blue Shield of California
El Dorado Hills, CA
07.2012 - 09.2017
- Developed comprehensive Auditing & Monitoring Guidelines for the AGD department, effectively measuring compliance and accuracy standards to ensure excellence
- Led AGD calibration meetings where in-depth case reviews were conducted, compliance metrics were scrutinized, and process gaps were identified, providing valuable insights to directors and supervisors
- Produced detailed analysis and recommendation reports, collaborating closely with AGD supervisors to pinpoint opportunities for improvement and leverage departmental strengths
- Conducted thorough monthly audits on the Appeals and Grievances Department (AGD) across all lines of business, ensuring strict compliance with healthcare regulations set forth by the Department of Managed Care (DMHC), Department of Insurance (DOI), and Office of Personnel Management (OPM)
Regulatory Coordinator
Blue Shield of California
El Dorado Hills, CA
- 07.2012
- Successfully managed member complaints submitted to regulatory agencies, including DMHC, DOI, and OPM
- Conducted in-depth research on various member complaints related to benefits, claims, medical necessity, coordination of care, quality issues, referrals, provider networking, prescriptions, durable medical equipment, enrollment, and premium billing
- Delivered comprehensive responses to member complaints, accompanied by all necessary documentation and Evidence of Coverage, within an expedited 24-hour or 3-5 working days timeframe, ensuring compliance with regulatory expectations
- Proactively collaborated with Blue Shield's legal department to effectively resolve member complaints when regulatory agencies challenged the health plan's final decisions
- Prepared and submitted Independent Medical Reviews to third-party Maximus, facilitating unbiased evaluations of complex cases
- Resolved escalated member issues directed at the Blue Shield CEO or executives with impressive turnaround times, demonstrating commitment to member satisfaction
- Addressed and resolved written correspondences from dissatisfied members addressed to the Blue Shield of CA CEO and executives, reinforcing our dedication to responsive customer service
Education
B.A. - Liberal Studies
California State University Long Beach
Long Beach, CASkills
- Auditing
- Claims Processing
- Collaboration
- Communication
- Complaint Management
- Compliance Analysis
- Compliance Monitoring
- Compliance Oversight and Advisory
- Data Analysis
- Documentation
- Enrollment Procedures
- Fraud, Waste, and Abuse Investigation
- Gap Analysis
- Healthcare Industry
- Healthcare Laws
- Healthcare Operations
- Health Insurance Concepts
- Internal Auditing
- Know-Do-Share (KDS)
- Leadership
- Legal Collaboration
- Legal Compliance
- Legislation Interpretation
- Maximus
- Member Complaint Handling
- Member Issue Resolution
- Microsoft Excel
- Microsoft Word
- Policy Development
- Problem-Solving
- Process Improvement
- Process Management
- Provider Disputes Resolution
- Quality Assurance
- Regulatory Compliance
- Regulatory Compliance Monitoring
- Regulatory Reporting
- Research
- Research and Analysis
- Stakeholder Communication
- Time Management
Timeline
Compliance Analyst II
Sutter Health Plus
09.2017 - Current
Operations Auditor
Sutter Health Plus
01.2017 - 09.2017
Senior Quality Consultant
Blue Shield of California
07.2012 - 09.2017
Regulatory Coordinator
Blue Shield of California
- 07.2012
B.A. - Liberal Studies
California State University Long Beach
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