PATRICIA R. SPENCER
Hilliard,OH
Summary
Detail-oriented Compliance Professional dedicated to improving regulatory communications across all business areas. Focused on ensuring timeliness, accuracy, completeness, and responsiveness of communications and submissions to regulatory bodies. Hardworking and driven with a quality-focused and proactive approach. Organized and dependable candidate successful at managing multiple priorities with a positive attitude. Willingness to take on added responsibilities to meet team and company-wide goals. Bringing 17 years of experience in Managed Care.
Overview
17
17
years of professional experience
1
1
Certification
Work History
Sr. Compliance Administrator
Buckeye Health Plan
2018.01 - Current
- Liaise with risk management, internal audit and employee services departments to direct compliance issues to appropriate channels for investigation and resolution.
- Establish and cultivated productive relationships with regulatory bodies.
- Oversee proper maintenance and dissemination of filing documentation as well as records and reports for review by various departments.
- Enhance regulatory, strategic and operational performance to keep in alignment with deadlines.
- Enhance accountability and responsibility for compliance by allocating tasks such as assessments, mitigation, and monitoring.
- Assist with preparation and submit regulatory filings in timely manner.
- Maintain composure in stressful situations, confrontations, interviews and records searches.
- Develop and maintained compliance database, tracking all compliance activities and documents.
- Monitor and assess compliance risks associated with operational processes and procedures.
- Assist with development of compliance objectives and strategies.
Compliance Specialist
Buckeye Health Plan
2012.11 - Current
- Performed quality reviews with Compliance Officer to uncover workflow and communication issues.
- Provided guidance, advice and training to improve business' understanding of related laws and regulatory requirements.
- Forged productive relationships with shareholder companies and internal departments.
- Oversaw proper maintenance and dissemination of filing documentation as well as records and reports for review by various departments.
- Established and cultivated productive relationships with regulatory bodies.
- Reviewed company forms, marketing materials and communication procedures for compliance with applicable laws and guidelines.
- Enhanced regulatory, strategic and operational performance to keep in alignment with deadlines.
- Served as subject matter expert by advising staff and working directly with external agencies throughout audits or to remedy compliance issues.
- Supported Compliance Officer by pitching in to complete special projects.
- Assisted with training sessions to educate management personnel on compliance and regulatory standards through in-person presentations.
- Maintained up-to-date knowledge of current and emerging compliance regulations.
Appeals Specialist Nurse
Buckeye Health Plan
2010.11 - Current
- Acted as departmental resource on appeals matters.
- Created, composed and maintained appeal response templates.
- Developed appeals functions, policies and procedures, and documentation.
- Reviewed outstanding requests and redirected workloads to complete projects on time.
- Verified client information by analyzing existing evidence on file.
- Communicated effectively with staff members of operations, and clinical departments.
- Maintained confidentiality of patient records and health statuses.
- Communicated verification and authorization status updates with Medical Management department to facilitate decision-making for patient admissions and insurance coverage.
- Coordinated with Medical Director's to compose appeal responses.
Prior Authorization Nurse
Buckeye Health Plan
2007.04 - Current
- Perform clinical reviews of authorization requests using appropriate criteria.
- Provide accurate and complete documentation with rationale used to approve request.
- Collaborate with various staff within provider networks and case management team coordinate patient care.
- Followed all personal and health data procedures to effectively comply with HIPAA laws and prevent information breaches.
- Evaluated patient histories, complaints and current symptoms.
- Recorded details regarding therapies to keep patient charts updated.
- Used first-hand knowledge and clinical expertise to advocate for patients under care and enacted prescribed treatment strategies.
- Advocated for and strived to protect health, safety and rights of patient.
Education
Bachelor of Science - Healthcare Administration And Leadership
Capella University
Minneapolis, MN05.2025
Associate of Science - License Practical Nursing
MPCC
Zanesvillle06.2003
Skills
- Expertise in Regulatory Compliance and Communication
- Regulatory Submissions
- Policy Creation and Analysis
- Reporting Requirements, Preparation and Management
- Risk Identification and Monitoring
- Contractual Compliance
- Information Security
- Trend Monitoring
- Process Implementation
- Documentation Review
- Compliance Oversight
- Strong history of providing excellent team leadership and management
Certification
2003-10 Licensed Practical Nurse
Timeline
Sr. Compliance Administrator
Buckeye Health Plan
2018.01 - Current
Compliance Specialist
Buckeye Health Plan
2012.11 - Current
Appeals Specialist Nurse
Buckeye Health Plan
2010.11 - Current
Prior Authorization Nurse
Buckeye Health Plan
2007.04 - Current
Bachelor of Science - Healthcare Administration And Leadership
Capella University
Associate of Science - License Practical Nursing
MPCC
2003-10 Licensed Practical Nurse
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