Randy Walters

• Developed strategic plans to enhance operational efficiency across departments.
• Collaborated with cross-functional teams to align project goals with organizational objectives.
• Analyzed and improved 150+ performance metrics to identify areas for process improvement and cost reduction.
• Facilitated communication between stakeholders to ensure project alignment and timely execution.
• Led internal/external audit activities (CMS, OIG, State DOI, EQRO, State Medicaid Agency) and regulatory reporting for consumer operations organization.
• Supported regulatory inquiries related to state and federal requirements.
• Created, Reviewed and Updated policy and procedures.
• Led talent development and succession planning, increasing associate engagement metrics year over year.
• Reviewed proposed regulatory changes and evaluated potential impacts on business operations.
• Leveraged data and analytics to make informed decisions and drive business improvements.
• Developed and implemented corrective action plans for compliance issues or risks.
• Assisted investigation, compliance and legal teams with fraud and investigations and risk identification.

• Developed compliance frameworks to align with regulatory requirements and organizational policies.
• Conducted risk assessments to identify compliance gaps and recommend corrective actions.
• Facilitated training sessions to enhance staff awareness of compliance standards and procedures.
• Collaborated with cross-functional teams to implement effective compliance monitoring systems.
• Analyzed policy changes and communicated impacts to stakeholders for informed decision-making.
• Led audits and assessments, ensuring adherence to internal controls and external regulations.
• Streamlined reporting processes, improving efficiency in compliance documentation and record-keeping.
• Facilitated cross-functional collaboration to address complex compliance issues, fostering open communication and efficient problemsolving.
• Advised senior leadership on emerging trends in regulatory enforcement, enabling proactive planning and strategic decisionmaking.
• Collaborated with management to develop effective strategies for addressing identified compliance risks and gaps.
• Managed relationships with external auditors and regulators during examinations or investigations, effectively addressing their concerns or inquiries.
• Conducted regular reviews of existing policies and procedures, ensuring continued alignment with evolving industry standards and best practices.
• Identified gaps in existing compliance processes and recommended updates.
• Evaluated third-party vendors for compliance risks, mitigating potential exposure to legal liabilities.
• Streamlined regulatory reporting procedures, ensuring timely submission of accurate data to relevant authorities.
• Developed metrics-driven approaches to tracking compliance performance across the organization, providing valuable insights into overall program effectiveness.
• Played a key role in the successful resolution of complex compliance issues, demonstrating strong problem-solving abilities and adaptability under pressure.
• Assisted investigation and risk management teams with fraud investigations and risk identification.
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• Streamlined operations by implementing process improvements and enhancing workflow efficiency.
• Led cross-functional teams to optimize resource allocation and achieve strategic goals.
• Developed training programs to enhance team performance and operational knowledge.
• Analyzed operational data to identify trends and drive informed decision-making.
• Managed vendor relationships to ensure quality standards and cost-effectiveness.
• Led hiring, onboarding and training of new hires to fulfill business requirements.
• Developed and maintained relationships with external vendors and suppliers.
• Analyzed and reported on key performance metrics to senior management.
• Managed budgets effectively, consistently delivering projects on-time and within financial constraints.
• Implemented quality control systems to boost overall product consistency and reliability.

• Reviewed and provided interpretation for new and/or updated legislative requirements related to the Medicare program.
• Developed detailed implementation project plans for assigned work load in accordance to Legislative and Regulatory Implementation Department (LRID) policy and procedures by analyzing all designated legislative items.
• Facilitated all work groups that contribute to assigned regulatory projects. Concentration of work groups involved included claims, enrollment, clinical, coverage determinations, grievance and appeals, actuarial, compliance, legal, internal audit, product and senior leadership.
• Successfully implemented many new and revised key CMS requirements including Grijalva and the Medicare Modernization Act of 2003.

• Oversaw daily operations, ensuring adherence to compliance and quality standards for a team of 20 to 50 customer service advocates in a fast-paced call center environment.
• Served as a coach and mentor for direct reports with a "lead by example" approach in hitting targets and holding myself and teams accountable.
• Led cross-functional teams to implement process improvements, enhancing service delivery efficiency.
• Developed training programs for new staff, fostering skill development and team cohesion.
• Analyzed performance metrics to identify trends, driving strategic initiatives for operational excellence.
• Improved customer satisfaction with timely response to inquiries, addressing concerns, and finding effective solutions.
• Enhanced operational workflow, identifying and eliminating bottlenecks in daily procedures.

• Call Center - Managed health plan member inquiries, resolved service issues and customer complaints, documented customer requests, and finalized policy adjustments.
• Call Center Team Lead - Trained call center associates, provided feedback and coaching to team members, assisted customers with escalated issues, monitored customer service metrics and provided reporting to leadership and analyzed customer service data to identify trends and opportunities for improvement.
• Medicare Operations Analyst - Reviewed Hospice and ESRD related enrollment and claims reports from the plan and the Centers for Medicare and Medicaid Services (CMS) to ensure appropriate capitation received from CMS for each beneficiary based on those health statuses. Other duties included working with market based clinical staff and CMS staff on collecting and reporting health status information.

Bachelor of Arts with majors in History and Political Science and a minor in Business Management