Tiffany Johnson
Somerset
Summary
Regulatory compliance manager with a strong foundation in health plan regulations and compliance oversight. Proficient in leading compliance investigations, managing vendor compliance, and translating complex regulatory requirements into actionable strategies. Committed to building robust compliance frameworks that enhance operational integrity and mitigate risk.
Overview
13
13
years of professional experience
1
1
Certification
Work History
Regulatory Compliance Manager
Horizon Blue Cross and Blue Shield of NJ
Newark
06.2024 - Current
- Maintained expert knowledge of legislative and regulatory health plan requirements for compliance.
- Served as SME on regulations for Horizon's LOBs reporting and required filings.
- Interfaced with enterprise leaders to guide operations on regulatory compliance matters.
- Led compliance meetings, overseeing investigations and corrective action plans for non-compliance.
- Monitored information sources for regulatory changes, developing mechanisms for ongoing updates.
- Developed a comprehensive compliance program, incorporating policies, procedures, and training.
- Compiled and distributed compliance dashboards based on established standards.
- Managed vendor compliance with CMS and DMAHS guidelines, ensuring effective oversight.
Regulatory Affairs Manager / Government Contract Lead
Molina Health
Brooklyn
12.2020 - 06.2024
- Reviewed and submitted member-facing marketing materials for state approval.
- Resolved all Department of Health and Department of Financial Services complaints through written communication.
- Managed relationships with key regulators to identify priorities and positions.
- Led contract renewal activities, including capture planning for rebids and submissions.
- Advocated for contractual rates and program improvements.
- Maintained day-to-day management of state contracts with Medicaid and marketplace managers.
- Oversaw implementation of new legislation, regulations, and contract amendments promptly.
- Served as primary resource for business units on state inquiries and regulatory filings process.
Sr. Regulatory Affairs Analyst
UnitedHealthcare
Iselin
12.2019 - 12.2020
- Perform critical and objective review of regulatory information.
- Determine whether business processes are consistent/compliant with applicable regulatory requirements.
- Collaborate with business partners to review, analyze and oversee/coordinate applicable implementation project plans from a regulatory perspective.
- Manage/monitor implementation to ensure that corrective actions and compliance plans are properly implemented.
- Create regulatory documents/communications/adhoc.
- Analyze and interpret new mandates and laws.
- Manage/implement applicable regulatory filings in a timely manner.
- Collaborate with applicable stakeholders to manage/support market conduct exams and performance audits.
- Monitored regulatory change required by new and revised laws and regulations, communicating complex protocols and determining operational impacts.
Grievance & Appeals Specialist
VNSNY CHOICE
New York
07.2017 - 12.2019
- Resolved grievances, appeals, and fair hearing reviews for VNSNY Choice product lines.
- Ensured regulatory compliance with timeliness and accuracy standards.
- Coordinated efficient daily operations for optimal workflow.
- Created and maintained accurate records documenting grievance and appeal decisions.
- Drafted correspondence to communicate outcomes of grievances and appeals to enrollees and providers.
- Assisted in collecting and reporting data for performance metrics.
- Coordinated external case reviews requested by enrollees, tracking progress effectively.
- Developed knowledge of state and federal regulatory requirements to ensure adherence.
Account Manager III
Horizon BCBSNJ
Newark
12.2015 - 07.2017
- Process and expedite the reconciliation of the member accounts for group administration while educating members and clients on benefits and referral protocol.
- Respond to inquiries from members and groups received by telephone or through written correspondence regarding benefits, enrollment, contributions and claims processing.
- Serve as Mentor and Coach CDH Account Consultants.
- Act as a liaison between Horizon, group administrators and CDH-related vendors and production support.
- Track data and Trend analysis as well as reporting.
- Coordinate administrative claims appeals on behalf of members.
Appeals Coordinator
Horizon BCBSNJ
Newark
12.2013 - 12.2015
- Identified reasons behind denied claims and worked closely with insurance carriers to promote resolutions.
- Acted as an intermediary between insurance companies and customers, researching and assessing information to validate claims.
- Coordinated with Blue Card Association Home plans to address customers' inquiries regarding claim, benefits and/or appeals.
- Contacted insurance companies to gather essential information on policies and payment benefits for patients.
- Ensured accurate and timely resolution of service requests and activities.
- Reviewed/escalated issues raised by customers in accordance with guidelines established by management.
Education
Master of Health Administration -
Rutgers University
New Brunswick, NJ01-2021
Bachelor of Science - Healthcare Management
Saint Peters University
Jersey City, NJ01-2017
Skills
- CMS & Federal Regulatory Compliance
- State Regulatory Filings
- Audit Management & Remediation
- Program Integrity & Risk Management
- Vendor & Delegate Oversight
- Policy Development & Implementation
- HIPAA / Privacy Compliance
- Regulatory Systems: CMS HPMS
- Regulatory Systems: State DOI Portals
- Regulatory Systems: NCQA
- Compliance Tools: Compliance 360
- Compliance Tools: SharePoint
- Cross-Functional Collaboration
- Training & Staff Development
- Microsoft Office 365
Certification
Lean Six Sigma Green Belt Certification, Rutgers University
Technical Skills And Systems
CMS HPMS, State DOI Portals, NCQA, Compliance 360, SharePoint, Microsoft Office 365 (Excel, PowerPoint, Word, Teams)
Timeline
Regulatory Compliance Manager
Horizon Blue Cross and Blue Shield of NJ
06.2024 - Current
Regulatory Affairs Manager / Government Contract Lead
Molina Health
12.2020 - 06.2024
Sr. Regulatory Affairs Analyst
UnitedHealthcare
12.2019 - 12.2020
Grievance & Appeals Specialist
VNSNY CHOICE
07.2017 - 12.2019
Account Manager III
Horizon BCBSNJ
12.2015 - 07.2017
Appeals Coordinator
Horizon BCBSNJ
12.2013 - 12.2015
Master of Health Administration -
Rutgers University
Bachelor of Science - Healthcare Management
Saint Peters University