Eva Legall, MBA, CIA, CHC

Experience

• 

  Group Health Inc.

  Oct 1995 - Nov 2007

  Conducted in-depth claim reviews to enhance operational and financial efficiencies, utilizing advanced analytical tools to pinpoint areas of significant impact and identify potential control deficiencies. Delivered valuable recommendations to proactively mitigate risks and enhance processes, leading to notable reductions in both risk exposure and overall operational expenses. Negotiated contract rates with diverse healthcare providers, strengthening the company's network across various sectors including physicians, dialysis centers, and homecare facilities. Collaborated with cross-functional teams to address operational issues impacting contract negotiations and implementation, while also conducting site visits to educate provider staff on policy changes for timely communication and compliance. Led provider recruitment efforts for PPO, HMO, and government program networks, while conducting on-site visits to ensure providers were informed of policy changes and to resolve contractual issues. Fostered collaboration across multiple departments to address provider concerns and enhance overall provider satisfaction through proactive measures. Managed online Rate, Diagnosis, CPT Crosswalk, and Procedure files, ensuring accuracy and accessibility. Developed annual rates for CPT codes utilizing approved methodologies, researched procedural nomenclature allowances from reputable sources like HIAA and RBRVS to create in-network fee schedules.

  • Internal Audit Project Lead

    Apr 2005 - Nov 2007

  • Contract Manager

    Sept 2003 - Mar 2005

  • Provider Relations Representative

    Jan 2001 - Aug 2003

  • Medical Rates Specialist

    Oct 1995 - Dec 2000
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  EmblemHealth

  Nov 2007 - Jul 2014

  Senior Auditor

  Conducted thorough audits in adherence to Institute of Internal Auditors (IIA) guidelines, ensuring the highest standards of quality and integrity were met. Delivered detailed audit reports, showcasing findings and actionable recommendations to the Audit Committee, while also providing supervision, training, and support for staff auditors in report writing.

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  VillageCare

  Jul 2014 - Apr 2018

  Delegated Oversight Manager

  Managed oversight of diverse entities, including Medicare Delegated Entities and Medicaid Subcontractors across multiple services, conducting annual risk assessments to ensure focused and effective audit coverage. Monitored monthly reports to ensure compliance with KPIs and SLAs outlined in provider agreements.

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  VillageCareMAX

  Apr 2018 - Apr 2023

  Director Healthplan Compliance

  Collaborated with the Chief Compliance Officer to develop the annual work plan, aligning audit activities with company objectives. Managed comprehensive audits of internal operations and delegated entities, ensuring strict adherence to compliance standards. Performed Revenue Cycle Management audits to align with regulatory and contractual compliance. Delivered tailored compliance training to new hires and provided targeted coaching to mitigate risk and foster a culture of compliance across the organization. Show less

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  VillageCare

  Apr 2023 - Jul 2024

  Senior Director Compliance & Internal Audit

  Led a diverse team of auditors in risk assessment, process enhancement, and operational audit completion, ensuring compliance standards were met. Performed Revenue Cycle Auditing to address any issues and optimize revenue efficiencies. Presented findings and recommendations to senior leadership and collaborated cross-functionally to drive efficiencies and foster trust. Directed annual risk assessment processes, formulated comprehensive audit work plans, assumed leadership for the annual MAR & CMS Compliance Program Effectiveness audits. Show less

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  Healthfirst

  Aug 2024 - now

  Sr. Manager Regulatory Compliance