PROFESSIONAL SUMMARY
Health Care Compliance Professional with extensive experience in overseeing all aspects of compliance and compliance review for major health insurers. Seventeen years of experience with 3 major Medicare Advantage Organizations (MAO) and Part D Prescription Drug Plans (PDP). Manage relationships with Centers for Medicare and Medicaid Services (CMS) to ensure organization compliant with federal regulations. Able to apply in-depth knowledge of regulatory requirements to the development and maintenance of internal policies and procedures. Adept in analysis and creating and implementing effective compliance solutions. Big picture thinker with ability to coordinate multiple details to meet critical objectives. Strong organizational and interpersonal skills with ability to develop solid working relationships.
PROFESSIONAL EXPERIENCE
Bravo Health, Baltimore, Maryland 2007 to 2011
(HealthSpring purchased Bravo Health in 2010)
Manager of Regulatory Management & Administration (RMA)
Corporate Compliance Manager
Oversee Bravo Health’s Medicare Advantage and Part D marketing and member material review and submission process. Perform material reviews and provide guidance to ensure compliance with all Centers for Medicare and Medicaid Services (CMS) regulations. Provide regulatory guidance and interpretation to Sales and Marketing, Membership Accounting and PDP Operations. Subject matter expert (SME) for marketing to provide regulatory guidance and interpretations to Sales and Marketing, Enrollment and Part D Operations; as a result Sales met critical targets. Implemented best practices and performed functional area training.
•Only MAO invited by CMS to contribute to testing and design of their new Health Plan Management System (HPMS) marketing module as a direct result of my in-depth compliance experience, knowledge of regulatory requirements, and understanding of MAO user needs.
•Interpreted Federal and State regulations for functional areas. Monitored implementation and adherence to same.
•Perform internal audits, developed reports for Chief Compliance Officer, recommend corrective actions and monitored remediation and maintained Corporate Compliance Program.
•Create, train and deliver quarterly presentations regarding CMS marketing Compliance requirements.
•Instrumental in achieving higher approval ratings on member and marketing materials.
•Prepared responses to state and local oversight agencies for sales and marketing complaints.
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Aetna Health, Blue Bell, Pennsylvania 1999 to 2006
(Aetna purchased Prudential HealthCare in 1999)
Corporate Medicare Compliance Manager
Monitored the Organization compliance with all Centers for Medicare and Medicaid Services (CMS) regulations.
•Coordinated integration of compliance requirements into product development, interpreting regulatory material, implementing compliance measures, and developing and communicating compliance procedures.
•Investigated impact of regulatory requirements, advising business units of solutions.
•Monitored adherence to compliance action plans. Developed response to CMS on member's rights and responsibilities for the Medicare products and helped business partners prepare for internal and external audits.
•Supported National Regulatory Compliance Team in cross-functional implementation of regulatory requirements.
•Instituted a policy to disseminate Advance Directives to all Plan Medicare members across the country.
•Wrote policies and procedures utilized by the departments during internal and external Medicare review.
•Supported the development, approval and implementation of new products for both Medicare Advantage and the Medicare Prescription Drug plans.
•Based on efficient management and submission of marketing material to CMS, Aetna was exempted from having a site visit.
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Prudential HealthCare, Atlanta, Georgia 1994 to 1999
Corporate SeniorCare Compliance Manager
Oversaw specific aspects of compliance policies and procedures for national Medicare and Medicaid plans.
•Examined material and made modifications as needed to expedite compliance review and approval process.
•Managed the internal and external review processes, providing proper documentation to speed completion.
•Ser...
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