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Yyyyyy x. yyyyyy

0000 xxxxxx xxxx , xxxx , xxxxx 00000 w (xxx-xxx-xxxx w


Health Insurance Compliance Professional

Accomplished w Client Centered w Detail Driven w Leader w Mentor w Highly Effective




      Extensive and progressively responsible experience in health insurance compliance management and interaction with regulatory agencies

      Excellent communicator with demonstrated ability to collaborate with staff, management, business partners and others at all organizational levels

      Outstanding blend of organization, prioritization, leadership and interpersonal skills

      Proven ability to lead and supervise team members, manage a wide range of duties simultaneously and coordinate multi-level directives within health insurance compliance and antifraud roles

      Mentor and lead teams by example and with integrity to deliver services excellence

      Consistent success is rooted within the combined concepts of quality, continuous improvement and effective process enhancements

Key Strengths

      Compliance Investigations

      Account Management

      Health Care Regulations

      Team Contribution and Leadership

      Analytical Problem Solving

      Customer Service

      Appeals and Grievance Procedures

      Communicating with Regulatory Bodies


Career Track


WellCare Health Plans, Inc., Tampa, FL 2001 2017

Senior Compliance Investigator (2008 2017)

         Proficiently investigated, assessed and remediated complex issues of compliance or sales and marketing, weighing information against all applicable standards including regulatory and Centers for Medicare & Medicaid Services (CMS) guidelines, internal policies and ethical practice.

         Conducted and documented interviews with relevant individuals including beneficiaries, sales agents, and associates. Determined investigation results and designed corrective action to prevent future occurrences.

         Identified and assessed risks, created effective mitigation measures to minimize future potential risk.

         Guided, coached and supported junior investigative staff.

         Maintained regular and timely communication with the Department of Insurances in all active investigations.

         Served on the company s Compliance Committee promoting compliance awareness and knowledge among company employees, focusing on the internal Compliance Week annual event.

Regulatory Affairs Specialist (2005 2008)

         Provided in-depth research support for the information needs of internal departments while also maintaining an array of assigned projects and investigations.

         Served as point of contact in daily interaction with the Florida Agency for Health Care Administration (AHCA) and directly communicated with the Department of Insurances in response to inquiries.

         Identified and coordinated resources necessary to ensure compliance program effectiveness and value, including maintaining relevant files and preparing detailed activity reports.



Yyyyyy x. yyyyyy, Page 2 of 2


Professional Experience, continued


         Researched regulations for the purpose of informing internal departments, developing compliance procedures, and drafting responses to queries by regulatory agencies.

         Tracked all issues referred to the Regulatory Affairs Department up to and including resolution.

         Collaborated with various functional areas to implement mandates, regulations, and corrective action plans.

         Assisted with Medicaid expansion, AHCA Fair Hearings, and creating reports for AHCA.

Customer Service Representative and Subject Matter Expert (2001 2005)

         Provided direct, customer-facing support for escalated issues raised by members and providers. Researched and resolved all matters to the satisfaction of the customer and for benefit for the company.

         Maintained meticulous records for each inquiry or complaint originating with members, providers, regulatory agencies, the Better Business Bureau, social media, legal department, AHCA and others.

         Clearly communicated with members to explain resolution of their inquiries, complaints and issues.

         Assisted care providers with billing issues and educated them in eliminating future problems.

         Served as liaison between internal departments and external partners in resolving unusual problems.

         Astutely identified trends and emerging member/provider issues and collaborated cross functionally internally to ensure enterprise wide solutions.


Education and Professional Development


Business Administration studies, Florida Metropolitan University, Tampa, FL


Professional Development

         WellCare Compliance Certification Program (WCCP), 2017

         Several FBI courses included in the Association of Certified Fraud Examiners (ACFE) testing:

o    Investigating on the Internet: Research For Fraud Examiners, 2016

o    Effective Report Writing For Fraud Examiners and Professional Interviewing Skills, 2015

o    Professional Interviewing Techniques and Conducting Fraud Investigations, 2014

         Cultural Competency, HIPAA, Fraud Waste and Abuse Core Training, Beneficiary Sensitivity, Code of Conduct, Interviewing and Investigation, Internet Investigation, and others


Additional Information


Volunteerism and Community Involvement

         Volunteer with Feeding America and Metropolitan Ministries, organizations assisting the poor or homeless


Technical Skills

         All components of Microsoft Office as well as Microsoft Outlook






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