General SRC #31, Attachment 2: Compliance Officer Resume
State of Florida Agency for Health Care Administration Statewide Medicaid Managed Care Program
General SRC #13, Attachment 2: Compliance Officer Resume Compliance Officer II-Senior Director Michelle Riegler, MS, MBA, LMHC, CHC Education, Licensure and Certifcation . Master of Science in Business Administration (Graduated with Honors), Nova Southeastern University . Master of Science in Mental Health (Graduated with Honors), Nova Southeastern University . Bachelor of Arts in Behavioral Science (Graduated with Honors), Lynn University
. Licensed Mental Health Counselor, State of Florida 1998 . Certified Healthcare Compliance – HCCA 2011 Experience Magellan Complete Care and Magellan Behavioral Health of Florida Compliance Officer, Senior Director 2013 – Present . Worked cross-functionally to start a new health plan including the development of essential operational substructures such as policies, program descriptions and oversight management tools and processes. . Responsible for successfully developing, implementing and overseeing the health plan’s compliance program since the health plan’s inception. . Responsible for communicating compliance and program integrity program activities and findings to the Magellan Complete Care Chief Executive Officer, Compliance Committee and in particular, as a regular presenter to the Board of Directors at their quarterly meetings. . Implements and maintains a system for confidential reporting and investigation of compliance concerns. . Responsible for developing, managing and auditing processes and strategies to evaluate the health plan’s internal control structures and compliance with all contracts and state and federal laws. . Responsible for developing appropriate recommendations in conjunction with the management of remediation of internal control deficiencies. . Intimately communicates and collaborates with the Special Investigations Unit to implement the program integrity plan and activities for the health plan. . Active member of the Senior and Executive Teams addressing all aspects of business operations and strategic initiatives. . Active influential participant in all delegated vendor and provider management joint operations meeting and internal operational meetings such as claims, health services and network management meetings to assure and enforce the health plan’s compliance within the highly regulated environment in which Magellan operates as a health plan. . Participant the pre-credentialing, semi-annual credentialing and annual credentialing delegated vendor audits with focus of all contractual and regulatory compliance components. . Redesigned operational departments’ processes to create compliant and efficient processes that positively impacted cost of care. . Responsible for the member appeal and provider disputes department.
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South Florida Behavioral Health Network, Inc. Vice President, CQI and Compliance and Chief Compliance Officer 2012 – 2013 . Responsible for developing, implementing and overseeing the compliance and program integrity program. . Responsible for communicating compliance and program integrity program activities and findings to the SFBHN Chief Executive Officer daily and to the Board of Directors as a regular presenter at their monthly meetings. . Active member of the Executive Team addressing all aspects of business operations, strategic initiatives and clinical program development. . Worked cross-functionally as an influential active team member with Finance and Contract Management in the operational management of over 100 providers which included community mental health centers, hospitals and FQHCs. . Redesigned the provider investigation process and documentation. Two major provider investigations lead and conducted by this writer resulted in the revocation of one provider’s contract resulting in a loss of over $7 million dollars and the eventual closure of the provider with the other investigation resulting in the removal of the CEO by the agency’s Board of Directors and the license revocation of the crisis stabilization unit. . Influential and active participant in provider procurement bids and contract negotiations. . Redesigned qualitative data mining reports that were used to evaluate utilization and care management creating meaningful reports that improved the organization’s way it managed providers. . Redesigned clinical departments’ processes to create compliant and efficient processes that positively impacted cost of care. . Assisted individual providers within the network with identifying and creating efficiencies that impacted their cost of care. . Responsible for the information technology and provider data/claims department. . Developed the company’s first Corporate Compliance and Ethics Program. Banyan Health Systems, Inc. Chief Compliance Officer and Director, Quality Improvement 2009 – 2012 . Responsible for the contractual and regulatory compliance of a multi-facility and multi-county company. . Responsible for developing, managing and testing processes and strategies to evaluate the agencies’ internal control structures and compliance with all contracts and state and federal laws. . Responsible for developing appropriate recommendations in conjunction with the management of remediation of control deficiencies. . Responsible for payment disputes and appeals for payor types such as Medicaid, Medicare and commercial insurances. . Responsible for all contractual and regulatory audits for all the facility sites and clinical programs. . Responsible for the company’s national accreditation and its quality improvement program. . Developed the company’s first Corporate Compliance and Ethics Program. . Developed internal investigation and auditing processes and documentation. . Over 20 successful external audit results. . External facing representative for the company to regulatory agencies and payors both building and maintaining successful relationships with same. . Successfully mitigating potentially significant financial penalties and sanctions due to immediate actions.
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Seacrest Resource Center, Inc. Compliance and Accreditation Consultant 2009 . Provided accreditation and regulatory consulting services for hospitals and community mental health centers throughout South Florida, New Jersey, and Ohio. . Responsible for compliance audits, process improvement, and organizational improvements aimed at increasing revenue and reducing cost. . Responsible for report presentation, training, and policy and procedure development. . Educated and assisted customers with navigating the reimbursement and provider dispute processes for their payors. . Co-contributor to the many successful accreditation audits to include new accreditation and renewal accreditation audits. Family Success Administration Division, Human Services Department, Broward County Government Interim Director / Assistant Director 2006-2009 . Responsible for a County Government Division with an annual budget of $11 million with 4 regional centers and a workforce of approximately 100 staff. . Responsible for communicating operational and funding activities to the Board of County Commissioners and to the Community Action Agency Board of Directors for the CSBG and LIHEAP Federal Funds at their monthly meetings. . Implemented strategic actions that maximized the cost of care. . Responsible for service provider procurement bids and contract management of providers for the Division. . Responsible for the oversight of the provider network that supported the Division’s strategic plans. . Increased number of people served per staff by 40% through organizational realignment. . Boosted state and federal grant support by 25%. . Improved divisional accountability by enacting formal policies/procedures including reviews of staff productivity and regional center output. . Consistently fulfilled administrative/departmental requests with deadlines as short as 3 days. . Streamlined staff productivity, heightened accountability, and improved customer satisfaction through continuous process improvement. . Enabled greater staff participation in decision-making by improving communications structures and streams. . Trained 250+ staff, applying human learning theory and diverse learning methodologies, using self-written curriculums recognized/approved by state licensing agencies. . Led division to receive its highest-ever marks compared to all previous accreditations. Substance Abuse and Health Care Services Division, Human Services Department, Broward County Government Special Projects Coordinator IV 2002 – 2006 . Responsible for developing, implementing and overseeing the compliance and quality improvement program. . Responsible for communicating compliance and quality improvement activities to the Board of Directors. . Responsible for monitoring of compliance vulnerability and risk, development/implementation of corrective action.
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. Reviewed/analyzed utilization of services and developed strategies to improve cost of care, quality assurance and improvement. . Responsible for accreditation activities, internal investigations, coordinated budgeting and accounting, and database management duties. . Privacy Officer for the Division and Department representative on the government county-wide HIPAA privacy committee. . Enabled 2 potential revenue streams by achieving preferred provider status with the Florida Department of Medical Quality Assurance and provider status with Medicaid. . Increased dietary unit savings 20%, and medical unit savings 15%, by conducting cost-benefit analysis and enacting changes including switching from a consultant to a staff member to provide specialized services to clients with chronic conditions like diabetes or AIDS, and addicts. . Increased speed of assessments/admissions, streamlined staff productivity, heightened accountability, and improved customer satisfaction through continuous process improvement. . Enabled greater employee participation in decision-making by improving communications structures and streams. . Trained 100+ staff, applying human learning theory and diverse learning methodologies, using self-written curriculums recognized/approved by state licensing agencies. . Led division to receive high marks on 2 accreditations. Atlantic Shores Hospital Director of Admissions, Utilization Review/Appeals and Outpatient Services 2000 – 2002 . Responsible for managing 3 revenue generating departments ensuring revenue maximization and loss prevention through successful payment appeals submission and ensuring appropriate and medically necessary admissions. . Saved $1.2 million in reimbursements by cutting outpatient service denial rate from 100% to 0%. . Increased reimbursement for inpatient services to 95%, generating $250,000. . Responsible for physician collaboration with patient admissions, utilization review and appeals. . Responsible for developing and maintaining collaborative and effective relationships with payors and managed care companies. . Improved documentation of client outcomes.
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