Raul Rodriguez

'Daily oversight of CTMs and grievances received from carrier partners related to our Licensed Medicare agents.

• Investigated reported compliance incidents thoroughly, identifying root causes and implementing corrective actions swiftly.
• Conducted thorough audits for improved risk management and mitigation strategies.
• Create, implement, and utilize routine compliance monitoring processes for all Medicare Sales Representatives
• Monitor implemented processes are in adherence with CMS Compliance requirements to ensure all Medicare Managed Care marketing and enrollment guidelines are followed
• Maintain up-to-date knowledge of all Centers for Medicare & Medicaid (CMS) regulations.
• Oversight, Audit, and monitoring of our team's daily work.
• Collaborated with cross-functional teams for consistent implementation of compliance initiatives across departments.
• Assign and monitor the day-to-day workloads for the Sr. and Compliance Specialists
• Reduced operational risks by conducting regular training sessions for staff members on key compliance topics.
• Provided expert guidance on relevant regulations, ensuring the organization stayed up-to-date with changing industry standards.
• Monitored KPIs and prepared evaluations, assessments, and reports.
• Supporting leadership in organizational goals and endeavors.
• Effectively assimilating, training, and mentoring staff and (when appropriate), cross-training existing staff and initiating retraining. This includes coaching to help increase skills, and knowledge and (if applicable) improve performance.
• Appraising performance, rewarding and disciplining employees, addressing complaints, and resolving issues. This includes providing regular and effective feedback to employees and completing timely and objective performance reviews.
• Maintained open communication channels with regulators, facilitating a positive relationship between the organization and governing bodies.

• Audit and provide recommendations to Analysts and coordinators' Grievances, Complaints, and Appeals for part C reconsideration and part D redetermination cases
• Report to Management audit results and findings by staff, composed of 5 analysts and 2 coordinators
• Identify areas of opportunity, develop and offer training to Internal Departments and staff
• Complete and audit weekly, quarterly, semi-annual, and ad hoc reports to management, CMS reports ODAG, CDAG, ODR, IRE Case files, and Stars reports
• Assist with Managerial duties, manage workload and Department operations
• Research, interpret, and enforce various sources of regulatory documentation including CMS Federal regulations, CFRs, and State regulations
• Audit Grievances and Appeals for part D redeterminations and part C reconsideration meeting Centers for Medicare & Medicaid Audit protocol standards ODAG and CDAG
• Managed and distributed monthly workflow of over 400 Appeals, 50 Grievances, and CTM Complaints
• Function as subject matter expert (SME) in performing analysis of current situations and recommending priorities and goals for future needs
• Ensured compliance with regulatory requirements by performing regular audits and staying up-to-date on industry standards.
• Conducted risk assessments to determine areas requiring increased focus during subsequent audits.
• Collaborated with cross-functional teams to identify areas of risk and implement preventative measures.
• Maintained confidentiality, handling sensitive information discreetly throughout all stages of the audit process.

• Audit & Monitor vendor's compliance with NCQA, URAC, ASES, CMS standards, Contractual agreements, and the company's policies and procedures
• Managed 7 vendors for 2 business lines Medicare Advantage and Medicaid
• Managed workflow of 5 auditors and 5 specialists
• Maintain track of Vendors Compliance Program, Annual audit of delegated entities functions and Financial statements, legal and financial risks
• Develop and administer Risk assessments and annual work plans to monitor the performance of delegated business partners and to meet regulatory oversight and compliance requirements
• Perform on-site and Off-site audits to ensure vendors follow Medicare & Medicaid regulations and NCQA standards
• Review and update Department policies and procedures
• Assist Manager with the development, implementation, and maintenance of the delegation Oversight Program and Annual work plan
• Develop corrective action plans and analyze Internal performance measures
• Design programs and strategies through communication and training that can help vendors comply with regulatory standards from CMS and their contractual agreement
• Provided detailed documentation on audit findings, facilitating swift corrective action when necessary.
• Streamlined audit processes, improving efficiency and reducing time spent on each audit engagement.
• Conducted risk assessments to determine areas requiring increased focus during subsequent audits.
• Ensured compliance with regulatory requirements by performing regular audits and staying up-to-date on industry standards.
• Coordinated, managed, and implemented auditing projects and prepared for evaluation.

• Handle complex escalated issues and concerns for all lines of business Medicare Advantage and Medicaid ASES
• Managed over 110 Appeals, complaints and Grievances on a weekly basis
• Followed Medicare, Medicaid Standards and regulations, First Coast and CMS billing guideline
• Interface with other departments or members and providers through written and verbal communications to handle complex and urgent customer situations; research complex member and provider complaints
• Interface with Government Agencies and Regulatory personnel
• Based on a member or provider complaint, identify correct classification of Appeals, Grievances and Complaints, audited written notifications to Maximus IRE, Members and Providers
• Analyze data collected and coordinate with member's treating providers and pertinent departments to resolve member's complaints
• Coordinate with Internal departments to effectuate resolution resulting from grievance and appeals resolution decisions made at plan level or by independent review entities.
• Collaborated with cross-functional teams to identify opportunities for process improvement and increased efficiency.
• Streamlined reporting procedures by creating user-friendly dashboards for easy access to key performance indicators.
• Reduced errors in data entry, instituting rigorous quality control checks.
• Managed multiple projects simultaneously while adhering to strict deadlines and quality standards.

• Managed provider calls, facilitating resolution of incoming requests and forwarding requests to appropriate internal Departments
• Collaborated with staff members to enhance customer service experience and exceed team goals through effective client satisfaction rates
• Investigated and resolved customer inquiries and complaints regarding claims, credentialing, contracting and Medicare regulations
• Trained staff and new hires on operational procedures and company services
• Answered average of 100 calls per day, addressing customer inquiries, solving problems and providing product information.
• Provided exceptional customer service by actively listening to inquiries and offering personalized solutions.
• Demonstrated empathy towards customer concerns, fostering trust and rapport during interactions.
• Enhanced team productivity through effective collaboration and communication with colleagues.
• Participated in regular team meetings, sharing insights on common issues faced by customers for collective problem-solving efforts.

• Managed over 200 medical claims on daily basis
• Billed Medicare Advantage, Medicaid and Commercial plan claims based upon established claims processing criteria
• Maintained knowledge of benefits claim processing, claims principles, medical terminology and procedures and HIPAA regulations
• Reviewed provider coding information to report services and verify correctness and Reviewed outpatient records and interpreted documentation to identify all diagnoses and procedures
• Performed billing and coding procedures for ambulance, emergency room, impatient and outpatient services
• Reviewed, analyzed and managed coding of diagnostic and treatment procedures contained in outpatient medical records
• Reviewed billing problems, researched issues and resolved concerns
• Trained and mentored staff on procedures, compliance requirements and billing claims
• Routinely conducted internal audits of financial records to detect discrepancies or potential fraud risks, enabling timely intervention and issue resolution.
• Created detailed reports for management reflecting key financial indicators such as receivables aging analysis, uncollected revenues breakdowns, write-offs statistics, among others contributing valuable insights into the department''s strengths and weaknesses.
• Reduced discrepancies in billing reports with thorough review processes and diligent follow-ups on outstanding accounts.