Highly accomplished and forward-thinking professional, with a proven ability to reduce compliance risks, increase efficiency, and stay ahead of changing regulations and technologies. A significant contributor to highly successful companies. World class leader, results oriented, positive and proactive, unparalleled work ethic, excellent focus and direction, in addition to, interpersonal and organizational skills. Adept at planning, executing, monitoring and reporting results.
Medicare Compliance Program Manager
2014 to Present
As the Medicare Compliance Program Manager, I serve as a focal point on all Medicare Advantage (D-SNP), and Cal MediConnect (CMC) compliance activities.
• Responsible for ensuring that all regulatory communications and guidance are communicated to internal business units, and our delegated entities.
• Along with the Compliance Office, I act as the liaison between L.A Care, and the regulatory bodies (CMS & DHCS).
• Responsible for ensuring that L.A Care, and our delegated entities are in compliance with the regulatory requirements.
• Responsible for ensuring that all reporting requirements, are collected and submitted to the regulatory bodies on a timely manner.
• Act as the subject matter expert on all Medicare related activities
• Responsible for internal & external audits, implementation of corrective action plans, and monitoring activities to ensure compliance across the board.
• Responsible for ensuring that all Marketing materials, are submitted to the regulatory bodies timely, and available to our beneficiaries
• Responsible for staff management, budgeting, staff workload, coaching and motivating my team, to produce outstanding results
• Responsible for ensuring that departmental interfaces, cross-training, staffing and process are established and maintained to increase operational capabilities, efficiencies and serve levels.
Medicare Compliance Advisor
2012 to 2014
As a Medicare Compliance Advisor I oversaw Medicare related compliance issues and projects in the Regulatory Affairs & Compliance department in the nation's largest public health plan. My responsibilities included but were not limited to:
• Coordinated and communicated all assigned D-SNP & CMC compliance activities internally, to LA Care's contracted provider network, and to subcontracting administrative services vendors.
• Assisted as a liaison with CMS and other federal agencies (DMHC) concerning LA. Care's D-SNP & CMC product lines.
• Ensured that L.A. Care and its delegated entities were in compliance with all CMS federal and any specific regulatory requirements related to D-SNP & CMC products.
• Worked with internal and external staff to correct performance deficiencies, ensured all applicable staff were aware of regulatory reporting requirements and submissions to regulatory bodies made timely.
• Acted as a subject matter expert to internal & external business partners.
• Oversaw CMS related audits and projects for resolution in a timely manner, and responded to corrective action plans (CAPs) request on deficient areas, by working with internal business partners on the creation of a CAP and or business plan
• Supported internal audits & external due diligent reviews
• Interpreted & supported staff in interpreting regulatory guidance. Ensured all deliverables from the guidance were completed and submitted to CMS timely.
• Worked directly with our CMS Marketing Manager and Account Manager to resolve Medicare related issues and or sought guidance on Medicare related questions.
• Led & supported our Medicare team in reviewing & submitting CMS Marketing and other materials via HPMS
• Trained and mentored the Medicare regulatory team members on various job related functions & regulatory requirements.
2012 to 2012
Successfully managed and oversaw Implementation and deployment of projects adopting the Agile methodology, for this leading 3rd party Health Insurance organization, to ensure that all projects are successfully managed, and delivered to the client on a timely manner.
• Led multidisciplinary project teams including: Developers, Stakeholders, Subject Matter Experts and other Project Team members.
• Worked with clients in establishing strategic and successful project strategies to ensure project is successfully implemented and launched on time.
• Defined and documented project scope for all projects
• Gathered business requirements and documented requirements using a Project Charter and by writing Project User Stories in Team Foundation Serve (TFS)
• Analyzed and communicated business requirements to the development teams
• Planned, and facilitated User Acceptance Testing, and tracked testing results
• Documented and distributed all project documents and reports, and communicated project progress to the Project Sponsor and other Stakeholders
• Possessed a clear understanding of the Software Development Life Cycle
• Attended daily scrum meetings with I.T development teams, to ensure the smooth implementation of the project. Reports any blocks to the Project Sponsor.
Medicare Operations Specialist
2011 to 2012
Successfully managed daily Operational projects and tasks in the Medicare Operations department, for the Medicare Dual Eligible Special Needs Persons (SNP) to ensure compliance with State and Regulatory rules, in the nation's largest public health plan.
• Provided guidance, reviewed and edited the annual model, pre-enrollment marketing materials to ensure that the organization remained in compliance with CMS Marketing guidelines and that the necessary materials were submitted to CMS timely for approval.
• Acted as a Subject Matter Expert for Medicare related operational issues and questions.
• Worked closely with the Regulatory and Compliance department, to ensure business units remained in compliance with CMS regulations.
• Worked together with the Regulatory and Compliance department on internal and external CMS audits. Helped gather the required documents for submission to CMS during audits.
• Worked closely with the Quality Improvement (QI) department as the Project Lead for the Medicare Star Ratings program.
• Monitored QI initiatives and identified QI opportunities, and worked with internal & external partners to meet quality thresholds on the HEDIS, CAHPS and HOS measures.
• Worked and reported QI progress to QI, Medical Management Directors and Project Sponsors.
• Worked closely with the Marketing and the Compliance and Regulatory departments to monitor the Medicare website activities, and update the website timely and accurately for submission to CMS.
• Monitored and tracked all CMS HPMS memos and Manual updates and worked with impacted departments to ensure that new regulations were met and policy and procedures updated to reflect the new change.
• Worked with the Medicare Part D benefit manager, the Pharmacy team and the Dental vendor to ensure compliance on all dental CMS related activities.
• Worked closely with member and retention services to ensure smooth service to our Medicare Beneficiaries. Updated the member service trainer on new CMS guidelines for training purposes.
• Attended CMS user calls for education purposes, and distributed information learned to the team.
2011 to 2011
Successfully strategized and managed high volume of long and short term projects. Including: Search Engine Optimization projects (SEO), Pay per Click projects (PPC), Social Media, and migration projects.
• Led multidisciplinary project teams including: Web developers, Stakeholders and project team members
• Engaged clients in establishing strategic and successful campaigns and worked with internal partners to develop, implement and launch successful campaigns
• Produced baseline reports to monitor project progress against and reviewed with clients
• Mapped out timelines, milestones, deliverables, and presented project plan to project stakeholders for approval.
• Assigned QA team members, assisted in preparing successful test case scenarios and end user testing prior to campaign launch
• Monitored project progress during implementation and after to ensure project success.
2010 to 2010
Managed entire loan cycle from client interview to funding. Audited client and lender-generated financial documents to ensure accuracy, quality, and compliance.
Business Analyst / Project Manager
2008 to 2009
Managed a high volume of projects and vendors on the commercial business segment of this leading non-profit corporation. Successfully strategized and managed project budgets up to $1.5 M.
• Led multidisciplinary project teams of up to 14 developers, and QA testers. Met project milestones within six weeks by prioritizing and directing efforts.
• Prevented loss of major accounts by identifying system loopholes and rebuilding infrastructure.
• Led client orientation and project assessment meetings as well as feedback sessions to clarify client requirements, business needs, and project objectives in collaboration with all stakeholders.
• Conducted business analysis of data feed requirements. Met all key deliverables deadlines.
• Mapped out timelines, milestones, communication processes, and key deliverables; gathered and documented business requirements. Presented to project sponsors for approval.
• Developed test cases. Performed QA testing with IT and end users prior to product launch.
• Prepared end user process flows, policies and procedures.
• Timed product launches to ensure system administrator support, developer resources, and content producer training on Content Management Systems and delivery strategies.
2007 to 2008
Responsible for monitoring Medicare & Medicaid product compliance with government regulatory agencies including MN Department of Health and Human Services, National Council of Quality Assurance (NCQA) and Center for Medicare & Medicaid Services (CMS).
• Successfully monitored and analyzed accreditation, legislative, regulatory and employer contracting developments to determine impact on BCBS of MN operations and workflow.
• Collaborated with business partners to develop corrective action plans for non-compliant contracts.
• Saved major government account by resolving audited deficiencies within tight contract deadline.
• Teamed with Operations Managers to implement audit plans and departmental assessments to monitor and track compliance.
• Drafted various legal and health care improvement documents and reports.
• Collaborated with credentialing team to achieve physician compliance. Proposed new staffing structure to achieve and ensure long term compliance.
Service Account Manager
2006 to 2007
Oversight for all operational functions of statewide key account including member and group eligibility and education, claims processing, relationship management, billing, and reporting.
• Provided product support on Medicare, Medicaid, HMO and PPO products; collaborated with internal business partners, clients and potential clients to resolve product issues.
• Successfully established two new markets with over $10M in annual revenues; identified key market players, developed strategic market plans in collaboration with sales and legal team.
• Led multidisciplinary team of staff and vendors to build infrastructure supporting plan design.
• Led member groups and brokers to monitor financial investments and customer satisfaction. Reviewed findings and created resolution plans to achieve contractual obligations.
• Saved major account from leaving group by educating members on benefits thereby significantly reducing claims expenditures by 65%.
• Converted long standing low customer satisfaction surveys to outstanding reviews within six months; recognized as Account Manager of the Year for achieving outstanding customer satisfaction.
Data Loading Analyst
2005 to 2006
Researched and analyzed physician and hospital claims to ensure accurate claims processing.
• Reviewed, monitored and maintained database systems to ensure secure access and use.
Computer proficiency: MS Word, Excel, Outlook, PowerPoint, Visio, Access, Groove, MS Project and Project Server, Team Foundation Server (TFS).
• Business Analysis • Project Planning / Documentation • Account Management
• Project Management • Quality Assurance Testing • Team Leadership
• Compliance Management • Self-directed • Agile Methodology
• Personnel Management • Action Oriented & Collaborative • Budgeting
• Strategic Planning • Marketing / Sales Support • Auditing / Monitoring