Teresa Warren
Darlington
Summary
Experienced with regulatory compliance and risk assessment. Utilizes strong analytical skills to identify and mitigate potential compliance issues. Knowledge of industry standards and best practices ensures organizational adherence to regulatory requirements.
Overview
37
37
years of professional experience
Work History
Compliance Specialist
Absolute Total Care- Centene Corporation
12.2024 - Current
- Performs comprehensive, complex regulatory analyses, including the review, summarization and dissemination of key regulatory updates and changes.
- Provides regulatory support and advice to business owners as new regulations emerge. Partners with business areas to help ensure processes and policies are implemented to comply with regulatory and contractual requirements.
- Monitors and reports on the status of assigned projects, anticipating and identifying issues that could inhibit achieving the project goals and objectives, and implementing corrective actions and mitigation strategies.
- Provides project leadership, including the review of documents, summarizing results and implementing recommendations.
- Performs special projects as assigned.
Senior Privacy and Compliance Specialist
Wisconsin Physicians Services
01.2019 - 08.2024
- Designed, developed, and continually updated the Privacy Incident process and work instructions to ensure compliance with all applicable laws, rules, regulations, guidance documents, and contracts.
- Monitored HIPAA Violation Reports, conducted assessments to determine reportability to designated oversight agencies.
- Coordinated with business partner Privacy Offices, responding to research requests and ensuring timely resolution of privacy incidents.
- Led coordination efforts to thoroughly investigate privacy incidents, ensuring adherence to established timelines.
- Provided feedback to operations management and IS personnel on errors resulting in privacy breaches, facilitating coaching actions for employees involved.
- Maintained accurate records of HIPAA violations and submitted reports as required.
- Reviewed and recommended updates to existing privacy policies and procedures to ensure alignment with legal, contractual, and regulatory requirements.
- Developed and implemented methods to educate employees on safeguarding Personally Identifiable Information (PII) and Protected Health Information (PHI).
- Created and distributed internal and external communications and training materials on compliance and privacy issues.
- Served as a privacy resource and Subject Matter Expert (SME), addressing privacy-related inquiries from employees.
- Established and updated policies using effective methodologies and existing functionalities.
- Conducted periodic monitoring of compliance procedures to ensure ongoing effectiveness of the Compliance Program.
- Assisted with ethics and compliance investigations within the division.
- Stayed informed about changes in the compliance and privacy environment, contributing to program updates as needed.
Provider Enrollment Manager
Blue Cross Blue Shield of South Carolina
01.2018 - 01.2019
- Monitored the provider enrollment process, reviewing, researching, analyzing, and processing provider enrollment applications.
- Ensured provider file integrity and compliance with established standards and guidelines.
- Conducted in-depth review and verification/validation of provider data to maintain accuracy.
- Provided high-quality service and effectively communicated with external and internal customers to resolve inquiries and discrepancies related to enrollment.
- Supplied enrollment applications and general information to interested enrollees, guiding them through the enrollment process.
- Contributed to and participated in special projects related to provider files, collaborating with Technical Support staff on system changes testing.
- Assisted in process improvements related to Provider Enrollment to enhance efficiency and accuracy.
- Managed multiple inventory reports on pending and processed provider enrollment applications, ensuring metrics were monitored and met.
- Coordinated compliance activities for PGBA and corporate lines of business (TRICARE, VA Choice, Medicaid, Medicare Advantage) in the Florence office.
- Maintained knowledge of industry trends, best practices, and government guidelines (CMS, DHA, HHS-OIG, DOD, DOJ, OCR).
- Ensured PGBA compliance with federal, state, and local laws and regulations.
- Completed annual operations risk assessments and internal control reviews.
Compliance Manager
Blue Cross Blue Shield of South Carolina
05.2014 - 01.2018
- Conducted HIPAA privacy and security risk assessments and audits, developing mitigation strategies.
- Provided compliance research and guidance to all levels of management, interpreting complex laws and policies.
- Coordinated with and hosted regulatory agency officials.
- Investigated misconduct and non-compliance, preparing formal reports for executive management.
- Managed hot line referrals and conflict of interest statements.
- Communicated follow-up on compliance-related exit interview remarks.
- Designed and tracked corrective action plans (CAPs) in the CAP database.
- Managed compliance content on the company intranet.
- Developed, implemented, and updated compliance policies and procedures.
- Prepared monthly summary reports on hot line activity, internal control reviews, PHI/PII disclosures, disciplinary actions, and investigations.
- Developed and delivered compliance training materials, collaborating with the training department for e-learning via LMS.
- Drafted communications to foster a culture of compliance, including a bi-weekly online compliance quiz.
- Provided compliance guidance on regulatory and ethical issues.
- Maintained positive relationships with internal stakeholders.
- Proofread senior management reports and presentations for the VP, PGBA Compliance Officer.
- Ensured compliance staff in the VP's absence.
- Volunteered as a corporate compliance training instructor.
- Assisted with internal investigations as requested by corporate compliance.
- Proficiently used Microsoft Office applications (Word, Outlook, Excel, Access, Publisher).
- Assisted in implementing and maintaining an ISO 9001 compliant system through annual internal audits.
- Managed key process audit data collection, analysis, measurement, reporting, and improvement suggestions.
Contracts Administration Manager
Blue Cross Blue Shield of South Carolina
09.2012 - 05.2014
- Managed change order proposals and coordinated their implementation.
- Ensured accurate and timely change order processes by coordinating with internal and external departments.
- Prepared and submitted change order proposals, updating cost proposals for Operations as needed.
- Participated in contract updates, ensuring timely and consistent administration of procedures and policies.
- Created and maintained project management tools for monitoring and reporting on changes, proposals, contract revisions, and training.
- Directed and supported staff in project implementation.
- Analyzed business requirements for change orders and drafted necessary changes and directives.
- Maintained effective communication with stakeholders and resolved conflicts within and between projects.
- Ensured compliance with performance standards and improved procedures and processes.
- Assisted in creating and implementing work improvements and action plans related to critical business processes and customer service requirements.
- Managed project budgets and resource allocation, including scheduling, planning, reporting, development, and implementation within timelines and budgets.
Compliance Manager
Blue Cross Blue Shield of South Carolina
06.2008 - 09.2012
- Developed, implemented, and monitored compliance programs.
- Conducted ongoing compliance training for employees.
- Ensured adherence to national standards and local, state, and federal regulations.
- Investigated and resolved compliance issues.
- Provided information on division compliance activities as needed.
- Supported operations management with projects involving business changes, system enhancements, contract directives, procedure analysis, quality control, strategic planning, and performance monitoring.
- Implemented a training program for managers to improve compliance survey scores, resulting in a 6.1% score increase from 2009 to 2010.
Customer Service and Claims Manager
Blue Cross Blue Shield of South Carolina
06.2006 - 06.2008
- Implemented a new Medicare Advantage contract for claims processing and customer service.
- Improved claims processing efficiency, increasing weekly productivity from 45-50% to 98%.
- Supervised customer service associates to ensure timely and efficient processing of correspondence and inquiries, maintaining contract compliance.
- Prepared and analyzed performance reports on pending and processed claims, adjustments, reprocesses, and quality audits.
- Administered quality control procedures to ensure compliance with corporate and contract guidelines.
- Maintained high levels of customer service with internal and external partners.
- Led projects on policy changes, quality improvements, and system changes, ensuring timely and accurate administration of policies.
- Identified and addressed change and error sheets, system errors, and served as the project lead for contracts and customers.
- Assisted with provider updates as needed.
Systems Support Manager
Blue Cross Blue Shield of South Carolina
05.2005 - 06.2006
- Ensured accurate interpretation, testing, and implementation of system changes.
- Developed efficient workflows for testing and implementing system changes, complex process analysis, and compliance with government program requirements.
- Acted as a liaison with information systems to ensure timely system modifications.
- Documented and communicated business requirements to facilitate system enhancements and modifications.
- Analyzed changes and prepared technical/cost responses.
- Led projects for contract changes.
Contracts Administration Manager
Blue Cross Blue Shield of South Carolina
09.1998 - 05.2005
- Ensured timely and consistent administration of corporate, contractor, and government healthcare policies.
- Initiated work requests for system changes or enhancements.
- Assisted in project budget preparation and monitored expenses for compliance.
- Managed staffing, including selection, training, appraisal, and development of team members.
- Ensured quality and productivity of departmental work.
- Provided education and training on policies and procedures to customers via various communication methods.
- Developed and implemented system testing procedures, improved techniques, and prepared reports and analyses for management.
Operations Manager
Blue Cross Blue Shield of South Carolina
08.1997 - 09.1998
- Supervised claims and documents processing team to ensure timely and efficient compliance with contract standards.
- Prepared and analyzed reports on pending and processed claims, adjustments, reprocesses, and quality audits to measure team performance.
- Administered quality control procedures, ensuring compliance with corporate and contract guidelines.
- Recruited and maintained a well-trained staff.
- Led projects on policy changes, quality improvement initiatives, and system changes, ensuring timely and accurate administration of policies and procedures.
- Assisted in budget preparation and expense monitoring.
Project Coordinator
Blue Cross Blue Shield of South Carolina
03.1993 - 08.1997
- Coordinated a variety of area-specific projects and process improvements.
- Supported projects by gathering information, preparing letters, reports, graphs, and forms.
- Created and formatted letters, reports, graphs, forms, and presentations.
- Streamlined workflow for management, maintaining highly confidential files and records in both paper and electronic formats.
- Managed and distributed incoming departmental mail and work requests.
- Maintained departmental logs, spreadsheets, and databases.
- Provided management with feedback on customer issues, keeping accurate records and following up on complaints until resolution or escalating as necessary.
- Recommended and assisted with improvements in procedures and policies for process enhancement.
Claims Processor and Customer Service
Blue Cross Blue Shield of South Carolina
01.1989 - 03.1993
- Researched and responded to correspondence and telephone inquiries according to desk procedures, ensuring that contract standards and objectives for timeliness, productivity, and quality are met.
- Completed adjustment and reprocessing for incorrectly processed claims.
- Processed claims according to regulations, standards and objectives.
- Examined and processed claims and/or non-medical appeals according to business/contract regulations, internal standards and examining guidelines.
- Entered claims into the claim system after verification of correct coding of procedures and diagnosis codes.
- Resolved system edits, audits and claims errors through research and use of approved references and investigative sources.
- Coordinated with internal departments to work edits and deferrals, updating the patient identification, other health insurance, provider identification and other files as necessary.
- Identified and promptly reported and/or referred suspected fraudulent activities and system errors to the appropriate departments.
Education
Bachelors of Science - Technical Management
DeVry University
Atlanta, GA06.2011
Associates of Applied Science - Business Administration
Florence Darlington Technical College
Florence, SC06.1987
Skills
- Proficient in Microsoft Office
- Regulatory compliance expertise
- Understanding HIPAA regulations
- Policy Development
- Training and Education
- Investigations and Assessments
- Communication and Collaboration
- Data Analysis and Validation
- Customer Service and Communication
- Project Management
- Process Improvement
- Report Management and Metrics Monitoring
Timeline
Compliance Specialist
Absolute Total Care- Centene Corporation
12.2024 - Current
Senior Privacy and Compliance Specialist
Wisconsin Physicians Services
01.2019 - 08.2024
Provider Enrollment Manager
Blue Cross Blue Shield of South Carolina
01.2018 - 01.2019
Compliance Manager
Blue Cross Blue Shield of South Carolina
05.2014 - 01.2018
Contracts Administration Manager
Blue Cross Blue Shield of South Carolina
09.2012 - 05.2014
Compliance Manager
Blue Cross Blue Shield of South Carolina
06.2008 - 09.2012
Customer Service and Claims Manager
Blue Cross Blue Shield of South Carolina
06.2006 - 06.2008
Systems Support Manager
Blue Cross Blue Shield of South Carolina
05.2005 - 06.2006
Contracts Administration Manager
Blue Cross Blue Shield of South Carolina
09.1998 - 05.2005
Operations Manager
Blue Cross Blue Shield of South Carolina
08.1997 - 09.1998
Project Coordinator
Blue Cross Blue Shield of South Carolina
03.1993 - 08.1997
Claims Processor and Customer Service
Blue Cross Blue Shield of South Carolina
01.1989 - 03.1993
Associates of Applied Science - Business Administration
Florence Darlington Technical College
Bachelors of Science - Technical Management
DeVry University
Similar Profiles
Karishia GlennKarishia Glenn
Care Coordinator II at Absolute Total Care (Centene Corporation)Care Coordinator II at Absolute Total Care (Centene Corporation)
Jerrell CoakleyJerrell Coakley
Data Analyst III at Centene Corporation, Absolute Total CareData Analyst III at Centene Corporation, Absolute Total Care
Daniel Allen WittrockDaniel Allen Wittrock
LTSS Care Navigator (Assessor) at Iowa Total Care - Centene CorporationLTSS Care Navigator (Assessor) at Iowa Total Care - Centene Corporation
LaTonya GattisonLaTonya Gattison
Retail Sales Manager at Adore llpRetail Sales Manager at Adore llp
Kelley Blackmon ByrdKelley Blackmon Byrd
Associate Head of School at Trinity Collegiate SchoolAssociate Head of School at Trinity Collegiate School