10 plus years at Humana with compliance monitoring, auditing, and grievances and appeals. Skilled in data analysis, root cause reviews, Excel reporting, and regulatory compliance.
Overview
1
1
Certification
12
12
years of professional experience
Work History
Compliance Control Monitor (Medical, RX, & APLS)
Humana
Atlanta, Georgia
03.2022 - Current
Supports process improvements by error reporting and identifying process gaps.
Excel tracker creation including pivot tables and weekly task reports.
Auditing Grievance and appeals for compliance supporting timely resolution.
Identifies process errors and sends coaching opportunities.
Compliance case monitoring reviewing at minimum 60 cases daily.
Apply Medicaid guidelines in case reviews.
Compliance Control Monitor (Medical)
Humana
Atlanta, Georgia
08.2021 - 03.2022
Monitored medical compliance cases for CMS adherence.
Collaborated to resolve compliance issues.
Provided member outreach to reinforce CMS and quality standards.
Medical Intake Coordinator
Humana
Louisville, Kentucky
11.2015 - 08.2021
Researched and reviewed claims to identify processing issues, code edits, prior auth requirements, and reprocessing needs.
Handled inbound calls for prior authorization requests, code edits, and claims.
Collaborated with internal and external stakeholders to resolve issues accurately and timely.
Processed incoming faxes for prior authorization requests, code edits, and claims.
Intake Coordinator
Omnicare
Louisville, Kentucky
12.2014 - 11.2015
Reviewed patient applications and documentation to determine program eligibility, ensuring compliance with guidelines and improving access to resources.
Collaborated with healthcare providers, case managers, and pharmacies to streamline and improve patient intake processes.
<ul><li>Assist in preparing Subs Annual Budgets and reviewing Subs financial reports.</li><li>Provide support and training to partners to ensure adequate support for the program component.</li><li>Conduct partner technical supportive supervision on request basis from Grants & Compliance teams.</li><li>Coordinate grantee proposal review process and ensure compliance with solicitations and donor regulations.</li><li>Coordinate pre-award evaluations and assessments of potential grantees as needed.</li><li>Analyze, verify and review grantees proposal budgets to ensure donor compliance and reasonableness.</li><li>Coordinate the assessment of grantee risk and implement appropriate systems and agreements to minimize risk.</li><li>Ensure timely and appropriate close-out of sub-grants and coordinate the close-out of EGPAF prime grants.</li><li>Provide support and training to partners finance staff to build financial and accounting capacity to ensure adequate support for the program component.</li><li>Monitor partners’ spending patterns as part of the overall project budget to actual analytics.</li><li>Follow up on Grantee monthly invoices & supporting documents</li><li>Serve as an expert on applicable policies, procedures, rules, and regulations and assist staff with their interpretation and understanding of these.</li><li>Stays abreast of donor policies, procedures, rules and regulations and host country legal requirements and informs local and regional management of significant changes.</li><li>Perform internal departmental/grants reviews ensuring compliance with Foundation and donor requirements. Identify potential areas of compliance vulnerability and risk; assists with the development of corrective action plans for the resolution of problematic issues; and provides general guidance on how to avoid or deal with similar issues in the future</li><li>Conduct on-site financial compliance reviews which include: cash counts; review of accounts receivables including employee receivables; documentation of segregation of duties and internal control structure; document storage and retention</li><li>Document findings, propose improvements or change as relevant, disseminate findings and ensure follow up implementation of recommendations as well as resolution</li><li>Conduct random surprise checks and vendor verification reviews to ensure proper procurement procedures are being practiced and report on findings</li><li>Develops an effective Compliance & Ethics training program, including appropriate introductory training for new employees as well as ongoing training for all employees and managers</li><li>Assists with improving the awareness and understanding of compliance to assist employees with the establishment of a “culture of compliance”</li></ul> at Elizabeth Glaser Pediatric Aids Foundation<ul><li>Assist in preparing Subs Annual Budgets and reviewing Subs financial reports.</li><li>Provide support and training to partners to ensure adequate support for the program component.</li><li>Conduct partner technical supportive supervision on request basis from Grants & Compliance teams.</li><li>Coordinate grantee proposal review process and ensure compliance with solicitations and donor regulations.</li><li>Coordinate pre-award evaluations and assessments of potential grantees as needed.</li><li>Analyze, verify and review grantees proposal budgets to ensure donor compliance and reasonableness.</li><li>Coordinate the assessment of grantee risk and implement appropriate systems and agreements to minimize risk.</li><li>Ensure timely and appropriate close-out of sub-grants and coordinate the close-out of EGPAF prime grants.</li><li>Provide support and training to partners finance staff to build financial and accounting capacity to ensure adequate support for the program component.</li><li>Monitor partners’ spending patterns as part of the overall project budget to actual analytics.</li><li>Follow up on Grantee monthly invoices & supporting documents</li><li>Serve as an expert on applicable policies, procedures, rules, and regulations and assist staff with their interpretation and understanding of these.</li><li>Stays abreast of donor policies, procedures, rules and regulations and host country legal requirements and informs local and regional management of significant changes.</li><li>Perform internal departmental/grants reviews ensuring compliance with Foundation and donor requirements. Identify potential areas of compliance vulnerability and risk; assists with the development of corrective action plans for the resolution of problematic issues; and provides general guidance on how to avoid or deal with similar issues in the future</li><li>Conduct on-site financial compliance reviews which include: cash counts; review of accounts receivables including employee receivables; documentation of segregation of duties and internal control structure; document storage and retention</li><li>Document findings, propose improvements or change as relevant, disseminate findings and ensure follow up implementation of recommendations as well as resolution</li><li>Conduct random surprise checks and vendor verification reviews to ensure proper procurement procedures are being practiced and report on findings</li><li>Develops an effective Compliance & Ethics training program, including appropriate introductory training for new employees as well as ongoing training for all employees and managers</li><li>Assists with improving the awareness and understanding of compliance to assist employees with the establishment of a “culture of compliance”</li></ul> at Elizabeth Glaser Pediatric Aids Foundation