Director, Government Audit - Medicare Part D @ Express Scripts
Associate of Arts (A.A.), Business Administration and Management, General @
Mesa Community College
A Client and Patient Services Champion whose inclusive leadership and innovative approaches yield multi-million dollar revenue contributions through intelligent strategic planning, strong communication and precision execution. A consummate professional with proven ability to adapt and thrive in a fast pace, high performance, unstructured environment with a complex, collaborative, diverse-oriented organization who consistently deliver star rated, best practice
A Client and Patient Services Champion whose inclusive leadership and innovative approaches yield multi-million dollar revenue contributions through intelligent strategic planning, strong communication and precision execution. A consummate professional with proven ability to adapt and thrive in a fast pace, high performance, unstructured environment with a complex, collaborative, diverse-oriented organization who consistently deliver star rated, best practice services to a wide range of clients and community interests. Strong acumen to attract talent and retain through motivation and personal development resulting in high performance, self-directed teams. Experience spans across multi-industries in the hospital & health care and financial services/banking industry.
Department of Health and Insurance Audit
Client Delegation Oversight
Review Requests for Proposals/Contracts
State/Federal Regulatory Compliance
Executive Management Reporting
Client Relationship Management
Lead Diverse High Performance Teams
Director, Compliance (Medicare) @ From January 2015 to Present (1 year) Director, Government Audit - Medicare Part D @ Primary responsibilities included internal audit support of Express Scripts' Prescription Drug Plan (PDP) is compliant and ensured adequate support of government and client initiated Medicare Part D Audits of delegated functions to Express Scripts is compliant with CMS Regulations and Guidelines. Additional audit support included actively participating in scheduled audit webinar sessions conducted by CMS, providing audit universes in CMS required format, data analysis, impact analysis and remediation plans as required by corrective or immediate corrective action plans.
Directed Government Audit Department which included a diverse team of 16 auditors and two audit managers in a high volume, stringent environment.
Ensured department specific performance metrics were met or exceeded through smart strategic planning and clear communication at all levels.
Presented Medicare Part D related information and results to various key stakeholders and clients which included the Chief Financial Officer and Vice President of Enterprise Risk and Audit.
Considered subject-matter expert in reviewing Request for Proposals (RFPs) related to Medicare Part D audit support and protocol.
Collaborated with Development Director to ensure training and development on audit protocols and application proficiencies including newly created training manuals.
Worked directly with Senior Director to review strategic plan/goals including operating budget and staffing requirements.
Tracked and reported client billing for audits conducted in excess of contractual agreement to Finance Department liaison.
Worked directly with Legal Compliance, Medicare Compliance Officer and Medicare Product to interpret and execute on new CMS Regulations and Guidance Releases.
Closed over 250 plus CMS and Client initiated Medicare Part D audits with no significant or material findings.
Met or exceeded stringent Client and CMS turn-around times 100% of time. From January 2013 to November 2014 (1 year 11 months) Greater St. Louis AreaDirector, Quality Management & Accreditations - Corporate Compliance @ Primary responsibility included working collaboratively across the enterprise, driving Express Scripts' Corporate Quality Program, with accountability for assuring favorable quality accreditation status. Served as organization subject-matter expert on quality program and accreditation-related topics, and driving organization decision-making related to desired enterprise quality accreditation portfolio.
Facilitated cross-organizational coordination of corporate-wide Quality Management Program, drove ongoing organizational interpretation of and compliance to quality accreditation standards.
Coordinated and oversaw accreditation reviews, which included monitoring onsite reviews by accreditation agencies.
Served as organizational subject-matter expert on quality accreditation standards and organization compliance.
Managed Quality Management Committee function as a critical component to quality program and supported other key quality committees.
Assessed vendors for possible quality accreditation implications (delegations).
Collaborated internally and with vendors to perform pre-assessment and ongoing delegation oversight review. Prepared and presented reviews to quality committee(s) and clients, as needed.
Directed organizational communication efforts related to quality, both internal and external, provided subject-matter expert content for RFPs.
Prepared and completed renewal of Express Scripts' Pharmacy Benefits Management and Care Continuum's Medication Therapy Management Program's URAC Accreditation.
Conducted vendor oversight reviews and presented report findings to both the Quality Management Committee and Clinical Integrity Council for approval.
Evaluated and recommended to the Quality Management Committee the Worker's Compensation Program URAC Accreditation be allowed to expire since there were no critical business need to maintain. A $150k cost savings. From July 2011 to December 2012 (1 year 6 months) Greater St. Louis AreaDirector, Utilization Management & Regulatory Compliance @ Primary responsibility was to ensure Express Scripts is compliant with relevant federal/state regulatory and accreditation requirements pertaining to Express Scripts' Utilization Management (UM) Program functions and led client audits of the UM functions.
Monitored and identified regulatory and accreditation requirements for UM functions.
Maintained Utilization Review Licensures and ensured compliance with such requirements.
Led impact analysis as new regulations occurred and communicated changes with key stakeholders in the organization which included financial analysis and collection of business requirements.
Led cross-functional teams and implemented required changes to remain compliant with regulations.
Subject Matter Expert for requirements on state, federal and agency levels and ensured adherence to requirements as deemed appropriate.
Understood audit protocol and led client audits of UM Program.
Maintained all policy and procedures pertaining to the UM Program which were presented to the Clinical Integrity Council (CIC) annually or as needed.
Conducted quarterly process audits of Mail Order facilities is compliant with UM function policy and procedures.
Served and participated as a voting member on the CIC as business owner of the UM Program.
Led and implemented four functional work streams during the Merger and Acquisition of NextRx PBM.
Submitted and acquired 13 new utilization review licensures as part of client contractual agreement.
Completed over 30 Client Delegation Oversight Reviews of the UM Program which resulted in compliant or no material findings resulting in hundreds of thousands of dollars in cost avoidance of performance guarantees.
Led multi-site locations of the Utilization Management Program for nine months as the Interim Senior Director of Operations which included 01/01 implementation of new clients. From October 2006 to June 2011 (4 years 9 months) Greater St. Louis AreaOperations Project Manager @ Oversaw the daily operation and high profile projects with full P&L accountability for a high-volume, inbound / outbound B2B contact center with 300 plus seats.
Directed a team of exempt and non-exempt professionals along with contractors.
Provided functional training on verification policies, compliance regulations, and banking requirements.
Proposed and implemented a newly created verifications function and applicable training manuals.
Collaborated with Talent Acquisition and Resource Staffing Agency to hire potential candidates.
Created and deployed functional policy and procedures compliant to state and federal banking regulations.
Worked directly with diversified product group sales team to prioritize premiere offerings to book of business.
Worked directly with Vice President of Risk to ensure compliant processes with verification protocol.
Reported collaborated with Fraud Unit and Enterprise Risk Management on potential fraudulent activity.
Created team and individual performance metrics to ensure timely handling of credit verifications.
Prepared and distributed daily, weekly and monthly performance reports.
Implemented functional training, customer relations, and quality assurance processes, increasing customer service levels by 30% for business bankers and small business clients.
Managed monthly and quarterly executive summary business letters along with operational efficiency reports, ensuring all functional service level agreements were achieved. From November 2004 to October 2005 (1 year) Accounting Operations Administrator @ Primary responsibility included working directly with the Vice President and Regional Operations Director to plan and forecast overall Loss Prevention Operating Budget in conjunction with the Corporate Financial Planning and Analysis Group.
Provided budgeting and financial analysis to multiple departments.
Produced monthly variance analysis on Profit and Loss reports, and prepared thorough monthly, quarterly, and year-end Profit and Loss statement reports.
Collaborated with corporate finance team, senior and executive management to prepare annual operational and capital budget forecasts.
Planned and managed an annual budget of $55 Million for 900 plus seat loss prevention B2C contact center.
Facilitated monthly consultation meetings with senior and executive level management to review expense budget variances and cost control strategies.
Recommended reallocations of funds in support of high profile business strategies and initiatives.
Planned the financial, operational and capital budgets with an average favorable variance of .009%.
Reduced the expense plan by $7 Million over a three-year period and achieved the targeted operating expense budget four consecutive years.
Developed, implemented and managed a business continuity plan along with facilitated compliance and regulatory trainings for three multi-million dollar business groups.
Managed support functions which included account payables/receivables and activity based costing. From November 1986 to October 2004 (18 years)
Business Administration @ University of Phoenix From 1991 to 1993 Operations Production Management @ Arizona State University, W. P. Carey School of Business From 1985 to 1987 Associate of Arts (A.A.), Business Administration and Management, General @ Mesa Community College From 1982 to 1984 Mark Loggins is skilled in: Medicare Part D, Utilization Management, Managed Care, Pharmacy Benefit Management, Medicaid, Health Policy, Healthcare, Medicare, Healthcare Industry, Disease Management, Health Insurance, Healthcare Management, HIPAA, Provider Relations, HMO
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