Edward D.
Senior Director, Network Compliance @Blue Shield of California
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WORK HISTORY
Senior Director, Network Compliance @Blue Shield of California
Los Angeles, CA, US
Conduct surveys in accordance with regulatory and accrediting requirements, analyze and report the annual variations. Assess compliance risks, identifying root cause of compliance exceptions and develop Corrective Action Plans to ensure comprehensive internal controls. Monitor all compliance activities for the Network Management Division, including network accessibility and availability (Commercial, Medicare, and Medicaid), transition planning, Block Transfer filings, network material modification filings, Timely Access Reporting and undertakings. Maintain Compliance Program and regulatory reporting policies and procedures to prevent prohibited or improper conduct. Provide evidence to meet regulatory examinations. Investigate and resolve legal and operational issues. Oversee provider communications and education. KEY ACCOMPLISHMENTS:• Manage a $4.5M budget and compliance, communications, education teams (16 employees), consistently meeting and exceeding objectives.• Merged regulatory compliance departments and policies for Commercial and Medicaid lines of business, and novated Medicare Advantage after company merger. • Developed industry guidance and policy for Advanced Access Program Verification.
EDUCATION
California State University, Northridge
Bachelor of Arts (B.A.), Geography
La Salle University
Doctor of Philosophy (Ph.D.)
Independence University
Master of Science (M.S.), Health/Health Care Administration/Management
La Salle University
Master of Science (M.S.)
Los Angeles Pierce College
Associate of Arts (A.A.), General Studies
ABOUT EDWARD D.
A top-performing Compliance Leader with 25 years of experience in the healthcare industry. Extensive knowledge of HIPAA, Anti-Kickback, False Claims, Stark Law and the seven elements of an effective Compliance Program to ensure consistent process improvement, facilitating loss minimization and antifraud initiatives. Establish and cultivate key relationships with regulators, providers, and internal/external clients to ensure beneficial outcomes and efficient operations. Spearhead internal teams through risk analysis and mitigation, internal auditing, and administrative compliance.Areas of Expertise include: Compliance & Accreditation Strategic Planning Process Improvement Healthcare Systems Relationship Building Regulations & Laws Benefits Administration Team Leadership Problem Resolution
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