Summary
Overview
Work History
Education
Skills
Certification
Timeline
Generic

Susan Bryan

Sunset Beach,NC

Summary

Strong leader and problem-solver dedicated to streamlining operations to decrease costs and promote organizational efficiency. Uses independent decision-making skills and sound judgment to positively impact company success.

Overview

19
19
years of professional experience
1
1
Certification

Work History

Senior Operations Manager

United Healthcare
10.2022 - Current
  • Lead and support day-to-day operations for Medicaid product in the most cost-effective manner within quality and clinical standards.
  • Strong background in government operations and management along with experience in a leadership.
  • Recommend policies, procedures, and standard operating procedure to guide the market in maintaining and improving its competitive position.
  • Strong collaboration skills across all departments to ensure smooth operations.
  • Identify and implement process improvements to increase efficiency and work to reduce costs and expenditures.
  • Ensure standards and integrity are maintained across the market.
  • Ensure deliverables are customized according to needs, specifications, and standards.
  • Collaborate with management to develop and implement processes to strength operational infrastructure of systems to accommodate objectives of the organization
  • Ensures measurement and effectiveness of all internal and external processes; provides timely, accurate, and complete reports on the operating condition of the market
  • Identify improvement opportunities for processes and offer solutions to promote optimal efficiency.
  • Reduced operational risks while organizing data to forecast performance trends.
  • Continuously assess emerging trends in operations management along with best practices in order to make informed recommendations for enhancements.
  • Built strong relationships with key stakeholders through consistent engagement, collaboration, and transparent communication practices.

CEO, Owner

Simply Compliance, LLC
03.2018 - Current
  • Recognizing, assessing, and proposing vendor solutions for compliance/regulatory concerns; monitor and participate in formulation of responses to external regulatory and legislative actions, tax changes, legal issues and audit matters and follow up on findings and action items.
  • Develop and implement continuous improvement strategies by translating business objectives into actionable projects.
  • Engineered communication and amplify the company’s continuous improvement philosophy, vision, and expectations.
  • Looks for opportunities to maximize efficiency and reduce waste.
  • Design projects to implement continuous improvement actions and achieve future compliance standards.
  • Track and execute cost reduction on process improvements
  • Leads organizational efforts in staying current with all pay for reporting programs, government regulations and improvement initiatives.
  • Establish an environment that creates incentives for, and eliminates barriers to, a team environment.
  • Articulates common goals and communicates how individual roles contribute to team success.
  • Proactively assess the need for change and obtains resources to implement change initiatives.
  • Administer decisions that produce high-quality results by applying knowledge, analyzing problems, and calculating risks.
  • Understands the overall financial performance of the organization.
  • Develop and instruct training modules on fraud, waste, and abuse; risk management; pre and post payment strategies; coding and encounter strategies; report writing and disseminating outcomes.
  • Internal audit program to leverage clients’ needs to meet organizational goals.
  • Monitored key business risks and established risk management procedures.

Vendor Manager

United Healthcare
07.2021 - 10.2022
  • Manage day to day relationship between business and complex vendors to ensure effective delivery of outsourced services
  • Primary liaison between vendor and business stakeholders to answer questions, provide performance metrics updates, manage capacity, and demand, and remediate escalations when needed
  • Facilitate vendor onboarding process through effective communications, site visits and training to educate the vendor on program/product/operational details and successfully transition business processes and/or operations
  • Partner with business leads to understand evolving service needs and expectations, define business requirements, and work with the vendor to improve capabilities
  • Establish and coordinate ongoing service level metric/performance reporting to monitor vendor performance and ensure contractual obligations and other performance guarantees
  • Analyze data and determine if there are gaps in performance and how to address improvements, training, and other interventions
  • Proactively identify potential risks to avoid sanctions to the Health Plan and/or vendor.
  • Conducted thorough risk assessments for potential vendors, mitigating potential disruptions to operations from unreliable suppliers.
  • Implemented project management techniques to overcome obstacles and increase productivity.
  • Increased transparency by implementing a robust vendor tracking system that monitored deliveries, invoices, and service level agreements.
  • Analyzed and solved multi-faceted problems that effected executive leaders and business initiatives.
  • Created reports, presentations and other materials for executive staff.
  • Cultivated strong relationships with vendors and partners supporting administrative operations.
  • Led cross-functional project teams to evaluate new technologies and solutions for integration into the company''s supply chain strategy.
  • Proven ability to learn quickly and adapt to new situations.
  • Organized and detail-oriented with a strong work ethic.

Senior Program Analyst

NC Department of Health and Human Services - Division of Health Benefits
12.2018 - 01.2021
  • Establish and employ Readiness Review Process(compliance) for implementation across contracted Managed Care Organizations (MCO), Provider Led Organization, Tribal Option for NC Medicaid Standard Plan
  • Develop the Readiness Review process and tools to utilize a comprehensive review of CMS, contractual, local/State rules, and regulations
  • Conducted weekly stand-up calls with all Prepaid Health Plans for the implementation for a comprehensive Readiness Reviews.
  • Monitored project milestones and deliverables closely, ensuring timely completion and adherence to established quality standards.
  • Gathered feedback from end-users throughout the implementation process, incorporating their insights into the refinement of ongoing efforts.
  • Developed and facilitated an internal training program to guide State resources for Readiness Review
  • Direct and assign projects while providing guidance to management and other project staff, as appropriate, to improve the efficiency of the division and of the Departments' Compliance procedures
  • Develop metrics and data driven reports and scorecards for executive leadership and the Secretary of DHHS for NC
  • Orchestrated strong process engineering, analytical and project management skills in leading Medicaid MCO's with compliance and regulatory compliance initiatives
  • Collaborate with key divisional staff and consultants to design, develop and implement strategies and plans
  • Executed corrective action and sanction matrix to align or provide additional guidance for sanctions to the MCO’s based upon compliance reviews, regulatory examinations, contract audits and/or industry trends as appropriate
  • Excellent organization and prioritization skills, including the ability to prioritize based on regulatory risk and business needs
  • Cross functional alignment with internal project areas for both Readiness Review and COVID-19
  • Project areas included are Claims/Encounters, Member engagement, Provider Credentialing, Program Integrity, PHP (prepaid health plans; includes MCO’s) SIT testing, Clinical, Population Health, Benefits, and Communications
  • Propose and mitigate potential risk with solutions and action items throughout the organization.

Audit Manager and Administrative Hearings Officer

NC Department of Health and Human Services - Division of Medical Assistance
05.2016 - 12.2018
  • Developed comprehensive audit plan to perform oversight audits, investigations, sanctions within the Scope, goals and timelines within NC DHHS compliance plan for NC Medicaid
  • Managed a team of auditors, ensuring accurate and timely completion of audit projects.
  • Conducted regular training sessions for audit staff, increasing their knowledge and skillset in the field.
  • Evaluated effectiveness of internal controls by testing key controls across various business units within the organization.
  • Spearheaded and maintained oversight of all audits performed for the Office of Inspector General (OIG), CMS, NC Office of State Auditor (Single Audit), Payment Error Rate Measurement (PERM) and ad hoc audits
  • Facilitated collaborative investigations, audits with State and Federal partners across NC provider network
  • Conducted Administrative Hearings as identified in NC Administrative Code, 10A NCAC 22
  • Administrative Hearings covered provider network (including Health Departments, Medicaid Providers, Local Management Entities/Managed Care Organizations, and Outpatient Services, skilled nursing facilities, intermediate care facilities (ICF-MR) and hospitals
  • Designed and implemented risk matrix for Federal, State and contractual audits
  • Execute overall provider compliance with Corrective Action Plans (CAP) and recommend liquidated damages
  • Proven strong relationships and communication skills with stakeholders.
  • Partnered with auditors to track errors and add contributions to maintain accuracy.
  • Led cross-functional teams in complex audits, ensuring seamless collaboration between departments.
  • Trained and mentored department staff on policies and procedures to establish strong foundation for client development and service activities.
  • Analyzed complex client problems and generated targeted solutions that resolved outstanding issues while enhancing business positions.
  • Recommended changes to management regarding financial operations.

Director, Special Investigation Unit

Eastpointe, Local Management Entity (LME) Managed Care Organization (MCO)
03.2015 - 05.2016
  • Engineered the design and development of the Special Investigations Unit for NC Medicaid program
  • Leveraged data analytics insights for informed decision-making in critical areas such as sales forecasting, budgeting, or personnel management.
  • Monitored office workflow and administrative processes to keep operations running smoothly.
  • Facilitated cross-functional collaboration for improved decision-making processes within the organization.
  • Instituted reporting templates to capture compliance data to executive team, board members and other stakeholders
  • Executed audits in collaboration with the State Bureau of Investigations, Medicaid Investigations Division, State of NC Division of Medical Benefits, Office of Inspector General and others
  • Collaborative NC Medicaid fraud, waste and abuse investigations with State Bureau of Investigations
  • Liaison for agency in legal matters for all fraud, waste, and abuse cases
  • Developed a comprehensive provider sanction tool
  • Develop and implement an annual audit plan for Medicaid provider network audits
  • Engage in prosecution of Medicaid mismanagement of funds as a result of provider fraud, waste, and abuse
  • Collaborate with NC State Bureau of Investigation (SBI), NC DHHS, local police departments, attorneys, as well as, testifying in Criminal Court
  • Executed a comprehensive fraud, waste and abuse training for internal staff, provider network, beneficiaries, and board members and other stakeholders
  • Collaborated with SAS, Inc to develop a agency specific Fraud, Waste and Abuse technology platform.
  • Tracked and evaluated risk and managed strategic relationships across all provider types
  • Lead bi-weekly meetings for the executive team; monthly meetings with the Board of Directors and other stakeholders to review the evaluated risk of network for fraud, waste, and abuse programs.
  • Observed each employee's individual strengths and initiated mentoring program to improve areas of weakness.
  • Monitored and coordinated workflows to optimize resources.
  • Recruited, hired, and trained initial personnel, working to establish key internal functions and outline scope of positions for new organization.
  • Demonstrated leadership skills in managing projects from concept to completion.

Director, Provider Monitoring and Program Integrity Units

Eastpointe, Local Management Entity (LME) Managed Care Organization (MCO)
01.2012 - 03.2015
  • Engineered the design and development of the Special Investigations Unit for the oversight of NC Medicaid program
  • Instituted reporting templates to capture compliance data to executive team, board members and other stakeholders
  • Executed audits in collaboration with the State Bureau of Investigations, Medicaid Investigations Division, State of NC Division of Medical Benefits, and others
  • Liaison for agency in legal matters for all fraud, waste, and abuse cases
  • Developed a comprehensive provider sanction tool
  • Develop and implement an annual audit plan for Medicaid provider network audits
  • Engage in prosecution of Medicaid mismanagement of funds because of fraud, waste, and abuse
  • Collaborate with NC State Bureau of Investigation (SBI), NC DHHS, local police departments, attorneys, as well as, testifying in Criminal Court
  • Executed a comprehensive fraud, waste and abuse training for internal staff, provider network, beneficiaries, and other stakeholders
  • Collaborated with SAS, Inc
  • To develop an electronic platform within Compliance 360 software to identify gaps and needs: fraud, waste, and abuse within the provider network
  • Tracked and evaluated risk and managed strategic relationships across all provider types
  • Lead bi-weekly meetings for the executive team; monthly meetings with the Board of Directors and other stakeholders to review the evaluated risk of network for fraud, waste, and abuse programs
  • Provided supervision and lead four teams of professional staff through comprehensive provider monitoring activities
  • Developed provider tools for monitoring activities of the network
  • Reporting member of the Contract Standards Committee in the development of the Request for Interest (RFI) and Proposals (RFP); monitored contract compliance, general procurements procedures, and Memorandum of Understandings
  • Vendor management, oversight, and program management
  • Initiated and managed the quality assurance/improvement project oversight
  • Managed contract standards committee across all provider types
  • Provided oversight of the contract and addendums with NC DHHS and Eastpointe for Program Integrity.
  • Recruited, hired, and trained initial personnel, working to establish key internal functions and outline scope of positions for new organization.
  • Trained and guided team members to maintain high productivity and performance metrics.
  • Reduced operational risks while organizing data to forecast performance trends.
  • Strengthened internal controls by reviewing existing policies and procedures, ensuring compliance with regulatory requirements.

Director, Policy, HIPAA, Compliance, and Advocacy

The Beacon Center Local Management Entity (LME)
08.2010 - 01.2012
  • Facilitated the oversight, development, implementation, and training of policy improvement, enhanced regulatory controls and provider contract compliance
  • Ensure HIPAA compliance standards were met by the local management entity (LME) and provider network
  • Facilitate monitoring plan of provider network for regulatory and contractual requirements
  • Vendor management, contractual and program management
  • Developed and executed cease and desist letters for providers not credentialed or contracted in the network
  • Spearheaded innovative approaches to resource allocation and strategic planning.
  • Developed training program for the provider network on advocacy, compliance strategies, and HIPAA
  • Executed teams across service area for community engagements.
  • Developed lunch and learn programs for Medicaid beneficiaries, providers and supports.
  • Reported out breaches to Office of Civil Rights and maintained register.
  • Coordinated the quality assurance/improvement project oversight
  • Cross functional teams collaborated to manage the ongoing project
  • Project types; secret shopper, REOMB, survey's, etc
  • Developed a mediation model with provider network to reduce grievance and appeals
  • Engaged with beneficiary, supports and/or other stakeholders
  • Executed and lead community integration of adults with SPMI from Adult Care Homes to independent living
  • Oversight of Client Rights committee and Consumer Family Advocacy Committee (CFAC) for beneficiaries receiving behavioral health services.
  • Observed each employee's individual strengths and initiated mentoring program to improve areas of weakness.
  • Developed high-performing teams by providing mentorship, guidance, and opportunities for professional growth.
  • Implemented innovative programs to increase employee loyalty and reduce turnover.
  • Optimized staff performance by designing comprehensive training programs tailored to individual needs.

Executive Director

Coco's Place, Residential Level 3, Behavioral Health
03.2005 - 03.2009
  • Facilitated network development and marketing for Residential Level 3 behavioral health group home for at-risk youth
  • Developed, designed, and implemented compliance program
  • Initiated procurement process for pharmacy; supply chain, resource, and vehicle management
  • Hire, terminate, supervise, and manage human resources
  • Participate in termination and unemployment hearings
  • Developed and managed relationship with oversight agencies
  • Participated in all audits, corrective action plans and hearings because of monitoring activities
  • Implemented billing process to ensure compliance with all contracts, state and federal rules and regulations
  • Developed all beneficiary and provider facing tools and information
  • Developed, initiated, and facilitated a comprehensive training for all staff
  • Supervision of staff to meet general statute and contract requirements
  • Supervision was provided to licensed and non-licensed professions as per supervision contract with each employee
  • Developed a comprehensive compliance and risk management program
  • Generated all tools, forms, and training for all stakeholders.
  • Optimized operational workflows, reducing overhead costs and maximizing resource allocation.
  • Strengthened internal communication channels to facilitate cross-functional collaboration and decision-making.

Education

M.B.A. Business Administration -

UNIVERSITY OF PHOENIX
Raleigh, NC
07.2011

B.S. Psychology and Business Management -

BARTON COLLEGE
Wilson, NC
05.1989

Skills

  • Microsoft Office Products
  • Management Team Building
  • Decision-Making
  • Analytical Thinking
  • Strategic Planning - Forecasting
  • Performance driven leadership
  • Budget forecasting
  • Conflict management
  • Risk management

Certification

  • Accredited Health Care Fraud Investigator
  • Nationally Certified Investigator
  • Notary Public
  • Project Management

Timeline

Senior Operations Manager

United Healthcare
10.2022 - Current

Vendor Manager

United Healthcare
07.2021 - 10.2022

Senior Program Analyst

NC Department of Health and Human Services - Division of Health Benefits
12.2018 - 01.2021

CEO, Owner

Simply Compliance, LLC
03.2018 - Current

Audit Manager and Administrative Hearings Officer

NC Department of Health and Human Services - Division of Medical Assistance
05.2016 - 12.2018

Director, Special Investigation Unit

Eastpointe, Local Management Entity (LME) Managed Care Organization (MCO)
03.2015 - 05.2016

Director, Provider Monitoring and Program Integrity Units

Eastpointe, Local Management Entity (LME) Managed Care Organization (MCO)
01.2012 - 03.2015

Director, Policy, HIPAA, Compliance, and Advocacy

The Beacon Center Local Management Entity (LME)
08.2010 - 01.2012

Executive Director

Coco's Place, Residential Level 3, Behavioral Health
03.2005 - 03.2009

M.B.A. Business Administration -

UNIVERSITY OF PHOENIX

B.S. Psychology and Business Management -

BARTON COLLEGE

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