Compliance Analyst Health Care

Elbe Simondo

Email: ****.****@*****.*** Phone: 858-***-****

Over two decades experience in privacy and compliance, data security, insurance claims/billings regulations, guidelines processes, policies and procedures. Centered around health care and non- healthcare setting.

Technical Background

Work Experience

Sharp Healthcare – San Diego, CA

Privacy Compliance Analyst (Aug 2023 – Present)

Investigating and assessing privacy incidents, responding to patient concerns/caller hotline, document findings of suspected and reported violations of laws and policies, assist with the remediation of privacy issues and document mitigation actions and necessary notifications.

Manages privacy breach data base, lead and manage privacy breach investigations and reporting process. Support regulatory responsibilities related to compliance with federal and state privacy statutes and regulations including HIPAA, state privacy laws, privacy policies and procedures.

Acts as liaison in join investigations between entities and affiliated practice or with another facility location.

Identifies, escalates, and follow up on privacy issues that required investigation, resolution, and legal action.

Develop and use privacy tools to lead and manage compliance activities, perform privacy risk assessments and other validation activities, investigate potential breaches and other allegations of noncompliance related to privacy matters, routinely monitor privacy related action plans through completion.

Develop and publish privacy newsletters/training documents for staff and/or workforce education on federal and state privacy education annual implementation to the entire organization. Skills Leadership & Management Skills, Project

Management, Six Sigma

Software MS Office, SQL, MS Visio, Protenus, Symplr and Real Learning Solutions.

Industry Experience

20 years

Education

B.S., Healthcare

Management and

Administration, University

of Phoenix

Training and

Certifications

HealthCare technology &

Cybersecurity.

HealthCare Privacy

Compliance.

Certified Cloud Security

Professional.

Workplace Investigation.

Regional Compliance &

Ethics.

HCC Webinar; Limited

Data Sets/Minimum

Necessary.

Challenges of supporting

HIPAA Compliance.

The Future of Healthcare

Technology and

Cybersecurity

Enforcement.

Tracking privacy legislation, conduct and summarize research when needed on relevant privacy laws and assist in managing compliance and data protection laws including implementation of new requirements.

Analyze and assess potential risks using privacy breach data, risk assessment data, federal and state, industry expert privacy trends, etc.

Manage Business associates (BA) inventory and evaluates proposed BA relationships. Review analysis and resolutions of BA agreements and other privacy related contract inquiries to ensure safeguarding of protected health information (PHI) in compliance with applicable state and federal laws and regulations. Sharp Community Medical Group – San Diego, CA

Senior Privacy & Security Analyst (Mar 2018 – Aug 2023)

Review regulatory requirements and potential business impact from an information security standpoint.

Provides ability in security policies, principles, and practices. Investigating information security incidents, collecting, preserving, and presenting evidence (e.g. admissibility, quality, and completeness of clear, chain of custody) in the components of a security incident response plan.

Assist SCMG independent physician practices about HIPAA privacy and security-to develop their best practices for employee training, security risk assessment and remediation, system downtime procedures, and disaster recovery/business continuity.

Help design and support a systematic and structured information risk management process for SCMG. Find and periodically evaluate SCMG's information security controls and

countermeasures to mitigate risk to acceptable levels.

Provide oversight for detecting, finding, analyzing security incidents.

Directed patients to exam rooms, fielded questions, and prepared for physician examinations.

Helped with routine checks and diagnostic testing by collecting and processing specimens.

Implemented care and efficiency improvements to support and enhance office operations.

Workday Learning and

Compliance Training.

Scripps Healthcare – San Diego, CA

Audit & Compliance Analyst (May 2017 – Mar 2018)

Performed a variety of technical duties and projects that are essential to advancing the overall goals and aims of the Scripps Corporate Privacy Program. Part of Audit, Compliance, & Information Security Department (ACIS), manages sensitive and confidential information and materials in support of the various daily activities.

Performs diagnostic reviews, risk assessments, checking reviews, investigations and audits related to confidential information, which includes both protected health information and personal financial information. Activities include monitoring access to various IS systems, medical records, and other documentation to assess adherence to set up policies related to privacy and protection of confidential information.

Reviews "Confidential Data" Authorization forms and makes recommendations for approval. Conducts privacy education for staff and physicians. Assembles and analyzes activity information and/or data and prepares written reports that will be viewed by senior management. Research laws and regulations as related to privacy and impact on policies. In addition:

*Conducts Privacy Risk Assessments, audits, and assist with design and implementation of Fairwarning routine monitoring review.

*Conducts Privacy Investigations, identifies root cause of discrepancies, prepares outcome reports, provides findings and mitigations.

*Reviews authorization and participates in Privacy education and awareness activities.

*Assist with department and compliance program performance improvement and effectives activities.

Sharp Rees Stealy Medical Group – San Diego, CA

Managed Care Coordinator (Aug 2010 – May 2017)

Reviews and finds authorizations, benefits information, obtain and organize data, prepare, and distribute reports within designated periods, calls to physician offices, health plans, providers, and vendors to aid in the care coordination under the guidance of the Case Managers.

Generate referrals and authorizations to streamline discharge planning process including denial notices base on NCQA guidelines.

Establish new user access to ACES-Authorization Claims Enrollment System and assign username and password for referrals and Coordination of Care for all subcontracted providers.

Collaborate with patient/family members, Case Managers, physicians, and healthcare providers. Encourage patients to self- direct care, self-advocate, and make decision when proper and to the degree possible.

Monitor progress in Essette and SharePoint Resource Home Page, Cerner, and TouchWorks.

Promote the best allocation of healthcare benefits and maximize efficiency in the use of the available resources and work alongside with Disease Management as well as Chronic Care Management Programs. Each program is evaluated with written description for managing care including behavioral health with the NCQA requirements from an organization.

Review /process admissions and reconcile between types of admission (Inpatient, outpatient, observation, obstetrics, and emergency), check eligibility, delivery, and collection of Choice Letter for ACO/Medi-care patients needing SNF or sub-acute placement, DME, or home health care.

Collaborate with patient and family of any changes needed in discharge planning.

Sharp Healthcare – San Diego, CA

2

nd

Level Appeal and Grievances Analyst (Aug 2004 – Aug 2010)

Research complaints (grievances) and log and track the information as it moves through the clinical process or is tasked through internal contacts

Contact health plan payer collect information and communicate disposition of the case, document all interactions

Review cases to determine if it needs further review by a clinician

Use sound, fact-based decision-making skills to render a decision for non-clinical complaints

Use appropriate templates to complete necessary

documentation for final appeals or grievance determination

Relay appeal or grievance information to members, providers, and internal/external parties within the appropriate timeframe

Create weekly statistical reports

Capture, investigate and respond to all complaints regarding customer grievances and appeals involving provision of service and benefit coverage issues.

Conduct pertinent research to evaluate, answer, and close appeals.

Ensure appropriate resolution to inquiries, grievances and appeals within specified timeframes established by either regulatory/accreditation agencies or customer needs; ensure appropriateness of the response in compliance with State and Federal guidelines.

Prepare response letters, notifications, and acknowledgements for members and provider complaints, grievances and appeals.

Maintain grievance information and supporting documentation in accordance with all state, federal, NCQA, URAC and other regulatory agency standards / regulations.

Escalate issues appropriately or work with other departments to resolve member issues.

Ensure all HIPAA and State requirements/regulations are always adhered to.

Identify issues and root causes of appeals and disputes for plan management and compliance.

Identify and report trends and/or areas of opportunities to supervisor.

Maintain and update appeal and grievance policies and procedures, member correspondence materials, and process manuals.

Perform internal audits of grievance and appeals process.

Maintain privacy and confidentiality of records, conditions, and other information relating to residents, employees and facility. Apria HealthCare – San Diego, CA

Accounts Receivable Specialist (Jan 2000 – Aug 2004)

Resolves complex payments, denial issues, finding root cause, recognizing payer trends on DME and infusion therapy claims.

Knowledge of technical and professional medical billings practices such as benefits. State regulations implemented in collections, ICD-9/CPT codes, and medical terminology.

Excellent telephone etiquette and support confidentiality and effectively under high volumes of work and deadlines as well as diligence with elevated level of accuracy.

Collected over $3.3 million of denied/under payment accounts resumed uncollectible. Assign to all four facilities and plans under Blue Cross. -Blue Shield, Great West, One Health Plan, CHG/Commercial Cigna, Sharp HMO, Children's SRS (Non- Cap). Review workflows and practices are recognized through NCQA.

Participates in the development, implementation and maintenance of policies, objectives, short- and long-range planning; develops and implements projects and programs to assist in accomplishment of established goals.

In collaboration with management team, defines and approves policies and procedures in a timely manner.

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