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Analyst Medical

Location:
Hialeah, FL, 33016
Salary:
62,000
Posted:
November 04, 2019

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Resume:

Matthew Colom

Compliance Analyst

Miami, FL *****

305-***-**** adaq80@r.postjobfree.com

PROFESSIONAL SUMMARY

Compliance Monitoring Analyst providing organization with key control checks for implementation and application of regulations and controls. Develop and deliver compliance risk-based monitoring programs which test efficacy of front-line controls. Excellent presentation skills and ability to identify key compliance risks.

SKILLS

•SQL

•Microsoft Powerpoint

•Excel-Pivot Tables, Formulas

•SHMS Medicare

•Auditing

•Internal audits/Mock Audits

•Microsoft Powerpoint

•Auditory attention

•Interdepartmental team collaboration

WORK HISTORY

COMPLIANCE ANALYST 03/2017 to Current

HealthSun Health Plans-Anthem - Miami, Fl

•Researched regulations from other sources of information

•Planned and presented meetings on compliance updates from CMS

•Oversaw and monitored Part D for metrics and audit purposes

•Took involvement in CMS audits

•Created and maintained detailed reports of the department's discrepant findings

•Surpassed and maintained target goals for compliance purposes

•Lead department to earn 5 Star Rating from medicare

PART D AUDITOR/CALL AUDITOR 02/2016

HealthSun Health Plans Inc. - Coconut Grove, FL

•Performed Compliance internal audits for preparation, reported investigative findings of discrepant practices to superiors to maintain compliance as per CMS g.uidelines Conducted auditing of Part D calls and proper documenation involving member coverage determinations

•Worked closely with Appeals and Grievances

•Identified differences between Cover Determinations, Grievances and Appeals Ensured resolution is provided to all calls were provided

•Conducted investigations in relations to FWA Fraud Waste & Abuse Planned and executed audits; collected, verified audit evidence, composed findings and conclusions, assisting in preparation for CMS and compliance mock audits

•Summarized findings and recommendations with Part D coordinators and presented to Superiors

PART D COORDINATOR II 12/2015 to Current

Matthew Colom - Hialeah, FL

•Acting liaison between pharmacies, medical centers, clinics primary care physicians, pharmacy benefit management and HealthSun Plan with all member issues

•Responsible for entering coverage determinations and identifying coverage determinations to manage case independently

•Initiated and executed direct member reimbursements/DMR Ability to identify, classify and document Part D calls accordingly Maintained electronic records as per CMS guidelines Ensured compliance with all HIPPA, OSHA and other federal, state and local regulations

•Managed approximately 50 incoming calls, emails and faxes per day from members and prescibers

EDUCATION

Florida Atlanta University - Boca Raton, FL Bachelors Business Administration

Business Administration

Broward College - Hollywood, FL AA

Business Administration

LANGUAGES

Spanish



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