Vicente Saldivar
Harlingen
Summary
Dedicated, results-oriented, and over 15 years of success in the areas of business and operations management, new business development, and regulatory environment space. Analytical, innovative professional with strong business acumen and deep technical knowledge dedicated to leading teams in meeting and exceeding operational targets.
Overview
13
13
years of professional experience
Work History
Sr Info Sec Risk Auditor
Enterprise Information Security
San Antonio, TX
12.2024 - Current
- Facilitate and respond to audits, RFI/RFPs from prospective and existing customers
- Support and facilitate communication and build trusted relationships with key business contacts including business proposal leaders, account managers, technical SMEs, legal, internal audit, privacy, and compliance to complete requests.
- Act as a liaison between auditors and application / business segments
- Facilitate and coordinate audit meetings with internal subject matter experts, legal, compliance, IT and operations teams
- Facilitate and direct technical questions to appropriate Optum Technology/Infrastructure and application teams, as needed
- Interact directly with Segment Security Information Officers and SMEs to address relevant security audit requests
- Provide inputs for process improvements, technology platforms and performance-based metrics and reporting requirements
Regulatory and Credentialing Manager
CaPS Provider Data Operations
Harlingen, TX
04.2021 - 12.2024
- Lead and coordinate requests for regulatory audits of credentialing files and corresponding documentation. Help create action plans and remediation efforts.
- Assist with creation of SOP’s, P&P’s, and annual regulatory updates to P&P’s.
- Experience working in a government, legal, health care, managed care and/or health insurance environment in a regulatory, privacy or compliance role.
- Coordinate and prepare materials as requested required for external and state audits to include lists of providers credentialed within required parameters, credentialing files, meeting minutes, and policies and procedures.
- Present collected information during external accreditation / regulatory surveys and Health Plan audits
- Manage, create, and perform structured audits that support the business unit priorities.
- Assume Credentialing Resolution Team Manager role including, but not limited to, personnel issues, payroll, performance evaluations, reporting, 1:1, project timelines and report directly to Compliance Manager.
- Manage existing Internal Audit Plan, Timetable of Projects and Duties, and an annual Internal Audit Evaluation of the year's performance and accomplishments. The evaluation will include the development and execution of corrective / improvement plans as appropriate.
- Create, execute, monitor and follow-up on corrective action and / or improvement plans resulting from less-than-optimal audit results
- Manage, validate, document, and implement sound audit sampling and scoring methodology.
- Proactively collect and include specific client requirements in audits, communicating to other team members, as necessary
- Collaborate with Leadership team to implement departmental policies and procedures, related to this position's responsibilities, including process flow charts.
- Compose and report monthly status reports of all activities in process and those completed for the month.
Regulatory Quality Supervisor
UHC National Credentialing Center
04.2021 - 04.2023
- Assume Audit Team Supervisor role including, but not limited to, personnel issues, payroll, performance evaluations, reporting, 1:1, project timelines and report directly to Compliance Manager
- Respond to and coordinate requests for external audits of credentialing files and corresponding documentation
- Coordinate and prepare materials as requested required for audits to include lists of providers credentialed within required parameters, credentialing files, meeting minutes, and policies and procedures
- Present collected information during external accreditation / regulatory surveys and Health Plan audits
- Manage, create and perform structured audits that support the business unit priorities
- Create, execute, monitor and follow-up on corrective action and / or improvement plans resulting from less-than-optimal audit results
- Manage, validate, document and implement sound audit sampling and scoring methodology
- Proactively collect and include specific client requirements in audits, communicating to other team members, as necessary
- Collaborate with Leadership team to implement departmental policies and procedures, related to this position's responsibilities, including process flow charts
- Compose and report monthly status reports of all activities in process and those completed for the month
- Assist with quality and process improvement activities including, but not limited to accreditation-related activities
- Manage existing Internal Audit Plan, Timetable of Projects and Duties, and an annual Internal Audit Evaluation of the year's performance and accomplishments. The evaluation will include the development and execution of corrective / improvement plans as appropriate
Service Account Management Supervisor
OptumRx- Prior Authorization
09.2019 - 04.2021
- Oversee the production of OptumRx Market Conduct Exams and Client Delegation Audits. Collaborate and remediate any outstanding outliers regarding the clients State and CMS contracts. Following up with any corrective action plans. Leading daily, weekly, and monthly calls for team to keep them updated with current and upcoming Commercial and State audits. Delegating and overseeing the work on the analyst work. Continuing to follow and stay up to date with Human resource issues or state regulations. Completing yearly evaluations and working with other leadership regarding monthly budgets.
- Agile Product Owner for development of analytic and data products
- Provides project management oversight to data and analytic development
- Gathering and documentation of project/product requirements
- Translate the business requirements into documented Agile user stories for the development team and communicate the details clearly
- Manages user story acceptance, and leads acceptance of technology releases
- Understanding of system architecture, data structures, operational workflow and business processes
- Works in Agile framework and know the roles and responsibilities
- Documentation of project(s)
Service Account Management
OptumRx- Member Services
11.2017 - 09.2019
- The Service Account Management Supervisor is the primary contact for day-to-day questions regarding OptumRx Customer Service capabilities and standards from the proposal organization and sales. As the internal expert for OptumRx Customer Service operational, strategic and technical products and services this position will offer guidance and expertise to support RFPs for prospective and existing clients. The SR SAM will hold delegated authority from department leadership as primary contact to review, approve or deny exceptions for Customer Service operational performance guarantees and business standards in bids. The SR SAM also supports department lead times for “service readiness” by providing regular updates to sales pipeline and future staffing requirements. Also working with CMS Grievance Audits for Member Services and a variety of monthly, quarterly, and yearly audit reports.
- Processes requests from Finance to provide cost for client’s service model, toll free numbers and other Customer Service programs, products.
- Helps create and maintain Customer Service content in the Sales Proposal database updated with current performance metrics and up-to-date responses for 140+ Customer Service FAQs
- Produces the weekly Sales Pipeline and updates department’s Business Continuity plan for department Leadership and Enterprise Workforce Management Report provides timely insight for service readiness and staffing requirements given lengthy lead times for hiring and training
- Works with Leadership annually and as needed to add and update department Business Standards and PG Standards for the new sales season
- Works with Workforce Management to validate FTE impacts from cost model based on new client membership and call volume forecast
- Determines incremental back-office staff needed by role and reviews FTE impact with the appropriate business manager or Director of Operations for approval on exceptions
- Builds, manages and maintains relationships with Operational peers
- Attends Client RFP and implementation kick off meetings
- Facilitates client site visit arrangements as needed for prospective client tour
- Assists Sales as needed to identify department leader to present in finalist meetings with client
Employer Installation Administrator
UnitedHealth Group- Community and State
Harlingen, Texas
11.2012 - 11.2017
- Responsible for the design, development, execution, and management of QA measures that impact critical business functions across multiple markets and systems. This includes multiple Ameri-Choice claim payment engines that drive off technical processes, table inter dependencies, outside tools, and complex regulatory rules and market-specific factors. Responsible for confirming the accuracy of new provider contract and amendment configuration, the setup of benefit packages and authorization rules, verifying claim system edits and third-party tools, and validating key system support tables. This includes developing and executing efficient and effective test plans for physician, institutional, and ancillary provider contract installation; member benefit package configuration; system claim edits and third-party tools, and system migrations, releases, and/or enhancements. Responsibilities: Perform capacity planning and reporting, claims related and business system analysis, responsible for all aspects of quality assurance, create and edit requirements, specifications, cost benefit analysis and recommendations to proposed solutions, facilitate development of process documentation.
Education
Pharmacy Technician Certification Board - Pharmacy
Harlingen
Texas09-2020
Bachelor of Science - Accounting
University of Texas- Pan American (UTRGV)
Edinburg, Texas12-2010
Skills
- Microsoft Teams – Expert
- Communications Skills- Expert
- Project Management – Expert
- Microsoft Office- Expert
Languages
English
Native or Bilingual
Spanish
Native or Bilingual
Timeline
Sr Info Sec Risk Auditor
Enterprise Information Security
12.2024 - Current
Regulatory and Credentialing Manager
CaPS Provider Data Operations
04.2021 - 12.2024
Regulatory Quality Supervisor
UHC National Credentialing Center
04.2021 - 04.2023
Service Account Management Supervisor
OptumRx- Prior Authorization
09.2019 - 04.2021
Service Account Management
OptumRx- Member Services
11.2017 - 09.2019
Employer Installation Administrator
UnitedHealth Group- Community and State
11.2012 - 11.2017
Bachelor of Science - Accounting
University of Texas- Pan American (UTRGV)
Pharmacy Technician Certification Board - Pharmacy
Harlingen