Michele Boley
Salisbury
Summary
Detail-oriented Compliance Manager offering 12 years of expertise in compliance/regulatory oversight, risk and issue management, policy development, reporting and strategic planning. Proven ability to develop and implement effective compliance programs. Strong leader with a focus on team collaboration and achieving results, adaptable to changing needs. Strong background working with federal and state regulators. Successfully led multiple compliance initiatives that enhanced operational integrity and regulatory adherence.
Overview
12
12
years of professional experience
Work History
Compliance Manager (Carelon Strategy)
Elevance Health
04.2023 - Current
- Spearhead compliance initiatives to standardize and streamline Issue Management, Audit Management, and reporting processes across the organization
- Develop and implement standardized and trackable regulatory practices across the organization by setting up clear policies and streamlined workflows
- Enhanced compliance reporting by designing streamlined documentation processes.
- Monitor and report on active regulatory risks and issues
- Enhanced internal controls with detailed compliance monitoring systems.
- Strengthened organizational reputation, maintaining high standards of regulatory compliance.
- Streamlined compliance processes by implementing efficient monitoring systems and tools.
- Played instrumental role in company-wide risk assessment efforts, supporting enhancements in business processes and controls.
- Routine trending and analysis to provide appropriate awareness and drive appropriate action
- Collaborate with compliance leads for timely updates for issues/risks in the Compliance Issue Tool
- Encourage accountability and champion a culture of performance measured by KPI metrics
- Develops and maintains internal policies and procedures and training documents
- Developed and maintains internal regulatory audit tracker
- Establish routines for analysis, tracking, trending, and reporting audit data to Carelon leadership
- Primary leadership duties involved strategic decision making, coaching, feedback, communication
- Regularly develop monthly, quarterly, or ad-hoc reports for senior leadership, highlighting progress in key areas and raising any potential issues and possible solutions
- Identify process gaps and implement process improvements
- Collaborate across multiple business areas and cross functional teams to drive compliance initiatives and process standards
- Facilitate Risk/Issue Management and Regulatory Audit Workgroups
- Formerly Anthem, Inc
Compliance Manager (Healthy Blue, North Carolina)
Elevance Health
06.2021 - 04.2023
- Partner with the Compliance Director to oversee and manage compliance activities that focus on driving the health plan compliance program and initiatives and responsible for ensuring compliance with our Alliance partner, State contract, and CMS regulations
- Reduced compliance-related incidents, implementing preventive measures based on audit findings.
- Developed strategic compliance initiatives to align with organizational goals.
- Collaborated with external auditors for annual compliance assessments.
- Primary leadership duties involved strategic planning, coaching, team building, performance feedback, communication
- Develop, implement, monitor, and support periodic review of all Health Plan and Compliance P&P’s, and submit applicable P&P’s to our Regulator for review/approval
- Research and interpret State and Federal legislative and regulatory updates, initiatives, and guidance to identify health plan impact, communicate to the business, and enter mandates/changes into Compliance 360 tool for tracking and assessments
- Identify, track, trend, and report on active risks and issues, and partner with the business to ensure effective remediation/mitigation is documented and corrective action plans are implemented when appropriate
- Monitored emerging trends in regulatory requirements, anticipating potential impacts on the organization''s operations.
- Regulatory filing and submission of regulatory reports, privacy disclosures, and State ad-hoc requests
- Manage, track, and coordinate with the health plan business to ensure State ad-hoc requests are responded to timely
- Execute corrective action plans arising from compliance issues that have not been effectively/timely remediated and adverse audit findings
- Support internal and external audits
- Regulatory submission of marketing collaterals to the State for filing, review, approval, including communication, tracking, and monitoring
- Develop and facilitate training and onboarding for new health plan associates and track and report on annual compliance training completions
- Along with the Compliance Director, develop content and lead the Health Plan Compliance Committee and actively participate in the Medicaid Compliance Committee
- Manage State issued member and provider complaints and work with health plan operations and key business areas to ensure timely response and remediation
- Communicate contract amendments with the health plan and ensure compliance with changes to requirements
- Meet with State regulators frequently to discuss current activities, emerging business, and remediation status of any operational/compliance issues
- Supports the Compliance Director in development of an annual Compliance Work Plan and documenting health plan activities that support key initiatives
- Develop and present reporting to executive leadership
- Formerly Anthem, Inc
- Coordinated cross-departmental initiatives to support compliance objectives.
- Succeeded in maintaining a positive relationship with regulators through proactive engagement and timely responses to inquiries.
Compliance Consultant Senior (dual role)
Anthem, Inc.
04.2016 - 06.2021
- Partner with the Compliance Director and Risk and Issue Management Oversight COE to oversee the Medicaid Compliance Risk and Issue Management Program for all Medicaid health plans to include tracking, trending, and reporting on active risk and issues, serves as admin for issue and risk tools (SharePoint), conducts outreach to risk/issue business owners for updates relative to risk mitigation, issue remediation, and draft and deliver associate communications and execute onboarding
- Regulatory submission of marketing collaterals to the State for filing, review, approval, including communication, tracking, and monitoring and oversight in CMAP, MRT and the internal activity tracker
- Responsible for submitting Fraud and Abuse referrals to the State
- Intake of State forwarded provider and member complaints, distribution of complaints to Medicaid IRU, and coordination of responses
- Managed the Compliance Assessment Tool (CAT) to include monitoring of contractual performance requirements through identification, assessment, communications, and tracking business owner responses; developed project schedule in coordination with Plan Compliance officers and demonstrated consistent effective systems and processes for monitoring and reporting, lead implementation of CAT into new markets, responsible for planning, presenting, and leading the quarterly CAT Steering Committee, lead monthly business owner trainings, and developed and updated all guidance documents and policy and procedures
- Develops, reviews, and updates internal policies and procedures and training documents, internal validations on a quarterly, semi-annual, and/or annual basis of Compliance Work Plans, Health Plan Committee Meeting documentation, and Marketing Integrity Plans
- Served as admin for Medicaid member and provider compliance reporting vendor, responsible for intake of hotline complaints and assignment to appropriate market and compliance staff for review and investigation, developed reporting of investigation metrics and trending for monthly, quarterly and ad hoc reporting to the Medicaid Compliance Officer
- Leadership duties include onboarding new associates, coaching, mentoring, communication
- Analyzed regulatory changes for impact on organizational operations and compliance strategy.
- Collaborated with cross-functional teams to align business objectives with compliance goals.
Manager/Process Expert (LTSS Medicaid)
Anthem, Inc. (Amerigroup)
10.2014 - 04.2016
- Supervised/lead an enrollment team of 6-10 to include hiring, coaching, team building
- Develops, implements, and periodically reviews departmental P&Ps
- Meets with State regulators monthly to report and discuss LTSS Medicaid enrollment issues and emerging activities
- Manages enrollment staff to meet department productivity metrics and goals
- Creates and approves reports for Regulatory submission
- Researches and interprets regulatory changes for impact on processes and implements changes to meet contractual compliance
- Analyze various data sources to ensure team is meeting State compliance as well as identify potential issues and gaps in procedures and implement changes
- Responsible for investigating, resolving/ and or escalating complaints in a timely manner
- Develops and improves business process workflows
- Manage and lead various projects
- Establish external working relationships with State agencies, community partners, and members
- Create reports, analysis, and trending for senior leadership
Senior Human Service Program Specialist
Florida Agency for Health Care Administration
06.2013 - 10.2014
- Regulatory authority lead for local Medicaid Region
- Directly involved in the implementation of the Statewide Medicaid Managed Care Program
- Functioned as a liaison between long term care facilities, providers, clients, and managed care plans
- Performed audits to identify fraud and abuse, conducted internal and external reviews, analyzed claims data and medical records to ensure compliance with Centers for Medicare and Medicaid Services, local, State, and federal laws and regulations
- Coordinated and presented education and training
- Managed special projects
- Analyzed claims data and processed claims appeals
- Managed complaint assignments, worked with the providers and managed care plans to resolve issues and close complaints timely
- Implemented innovative outreach initiatives that increased community awareness about available programs and services.
- Championed organizational change initiatives that improved overall service quality and responsiveness to client needs.
- Established strong partnerships with external organizations to enhance resource accessibility for clients.
Human Services Program Specialist
Florida Agency for Health Care Administration
12.2012 - 06.2013
- Regulatory lead for Local Medicaid Region
- Assisted providers with Medicaid policy and contract questions and well as claims and eligibility issues
- Managed special projects
- Analyzed claims data and processed claims appeals
- Managed provider directory/database; outreach and recruit
- Assisted with Fair Hearings and acted as Fair Hearing Coordinator
- Reviewed re-credentialing packets
- Reporting
Education
BA - Health Administration, Business Administration
Florida Atlantic University
Boca Raton, FL12.2011
Associate in Science degree -
Broward College
Coconut Creek, FL05.2008
Skills
- Regulatory and Compliance Monitoring and Oversight
- Risk and Issue Management
- Regulatory Submissions
- Team Leadership and mentoring
- Policy and Procedure Development and Monitoring
- Program/ Project Management
- Process Improvement
- Audit support
- Training Development and Facilitation
- Reporting for Senior/Executive Leadership
- Fosters and cultivates building professional, long-term, and strategic relationships
- Advanced skills with Excel and SharePoint
Talentprofile
- Regulatory and Compliance Monitoring and Oversight
- Risk and Issue Management
- Regulatory Submissions
- Team Leadership and mentoring
- Policy and Procedure Development and Monitoring
- Program/ Project Management
- Process Improvement
- Audit support
- Training Development and Facilitation
- Reporting for Senior/Executive Leadership
- Fosters and cultivates building professional, long-term, and strategic relationships
- Advanced skills with Excel and SharePoint
Timeline
Compliance Manager (Carelon Strategy)
Elevance Health
04.2023 - Current
Compliance Manager (Healthy Blue, North Carolina)
Elevance Health
06.2021 - 04.2023
Compliance Consultant Senior (dual role)
Anthem, Inc.
04.2016 - 06.2021
Manager/Process Expert (LTSS Medicaid)
Anthem, Inc. (Amerigroup)
10.2014 - 04.2016
Senior Human Service Program Specialist
Florida Agency for Health Care Administration
06.2013 - 10.2014
Human Services Program Specialist
Florida Agency for Health Care Administration
12.2012 - 06.2013
Associate in Science degree -
Broward College
BA - Health Administration, Business Administration
Florida Atlantic University
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