Healthcare Executive with a true entrepreneurial spirit and leadership skills experienced in leading teams in corporate, multi site, and start-up organizations. Rare double threat with proven results and in-depth hands on experience in both operational and compliance environments.
*Experienced leading significant results oriented teams in both Medicare and Medicaid programs.
*Experienced in all Executive interactions including key discussions at the Board Level
*Excellent contacts and relationship with CMS regional and central office.
*Led Star Score transformation teams resulting in organizational transformation and increase in Star Metrics.
*Experience and In-depth knowledge of Medicare and Medicaid area including Enrollment, re-credentialing, Sales/Marketing, Customer Service, Claims, Provider Relations, Credentialing Revenue Reconciliation, Appeals, Grievances, SNP operations, Quality, Part D oversight, and Compliance
*Experienced In NCQA accreditation process and getting excellent accreditation
*Experienced in building Compliance, FWA, HIPAA programs from ground up
*Detailed understanding, knowledge, and experience of implementing sales/marketing strategies to enhance growth opportunities.
*Experienced in leading and responding to all regulatory inquiries including audit activities, monitoring efforts, and relationship building.
*Experience in preparing, launching, formalizing corporate policy procedure/audit Monitoring/training/ standards of conduct/training program/ QC programs for enhanced compliance.
*Experience with Bid Submission and Encounter/RAPS submissions
*Experience in removing CMS Corrective Action Plans and sanctions
*Excellent executive project management skills understanding details of all sides while a reputation of delivering on key metrics.
*Experience with producing marketing materials with hands on experience in ANOC/EOC; summary of benefits, and directory documents
*Experience People manager with reputation of building, leading and managing teams that are a model of excellence
*HISTORY OF PROVEN RESULTS IN OPERATIONS, COMPLIANCE, AND QUALITY
Chief Compliance and Privacy OfficerNov 2010 to Current Freedom and Optimum HealthCare － Tampa , Florida
An HMO with 110,000 Medicare and 28,000 Medicaid members.
Oversees Corporate Compliance, Delegation, and Privacy Program to ensure compliance with all Federal and State Regulations are met.
Started with the Organization in its infancy during heightened membership growth and regulatory scrutiny.
Immediate close out of Open Caps within 6 months of start.
No CMS CAPS over the last four years.
Reports directly to the CEO and Board of Directors.
Excellent hands on experience building and leading all steps of the Corporate Compliance, HIPAA, and FWA programs from ground up.
Excellent relationship and contacts with CMS regional and central office.
Executive reporting to the CEO, Compliance Committee, and Board of Directors on a quarterly basis including chairing the Compliance Committee.
Conceived and launched a corporate wide Medicare Star Metrics team that directly resulted in an improvement from 2.5 stars in 2011 to 4.5 stars for 2014.
Directly responsible for developing ANOC/EOC, Summary of Benefits, all marketing advertisement reviews, and training of sales/Marketing agents.
Lead and manage corporate delegation team including Pre-delegation process, Delegation Committee, Monitoring, Auditing, and FDR oversight.
Lead, managed, developed corporate complaints team and processes to ensure all complaints were resolved expeditiously and satisfactorily.
This included but not limited to complaints from CMS (CTM, Regulatory, Central office, FWA), AHCA (DOI, DFS,), and Internal (Marketing/Agent oversight, Hotline, and HIPAA complaints).
Developed hands on metrics driven monitoring program across 10 different functional units resulting in proactive compliance approach and reducing member abrasion.
Led implementation of key corporate wide systems in the organization from the planning side to the execution side including but not limited to grievance systems, CTM database, Policy and procedure database, Regulatory guidance (including HPMS Memos) database, Annual training system/repository, enrollment system, provider portal, and agent/broker database.
In-depth knowledge and part of successful teams put together for Bid submission, Encounter submission, Applications, NCQA Accreditation, and all critical corporate submissions.
Lead and conceived corporate wide risk assessment that was then adopted as a CMS best practice.
Implemented a robust result oriented Part C & D audit/monitoring oversight program including but not limited to Organizational Determinations, Coverage Determinations, Grievances, Enrollment timeliness, Letter generation timeliness, CS information accuracy, OEV monitoring, network adequacy, credentialing, new hire and annual training, Sales/marketing reviews, Encounter error rate, Website reviews, Transition, Mail Order program, Formulary administration, PDE submission, and P&T program.
Direct point of contact and lead all regulatory audits including CMS Audit, RADV, AHCA audit, financial audits, and CMS Monitoring activities.
Director of Quality, Audit, and PMOApr 2007 to Sep 2010 Tampa, Fl
Responsible for leading program management office, business analysis, risk management, process improvement/six sigma, knowledge sharing, and performance management.
Reports directly to the Chief Operating Officer.
Created and managed the first operations wide 10 member project management group focused on large scale business process changes across 8 different business units.
Span of responsibility was to coordinate the effort of 8 programs and 30+ projects that comprised of the transformational effort.
Example of projects included implementing a new eligibility system, outsourcing of core functions to vendors, reduction of member/provider correspondence, and reduction of customer service calls.
Conducted operations wide strategy meetings that resulted in the implementation of a Disasters recovery plan in case of an emergency.
Process Improvement/Risk Management.
Led efforts to assist with CMS issues corrective action plans (CAPs) and milestones necessary to lift sanctions that suspended enrollment and marketing of Medicare Advantage (MA), Medicare Advantage Prescription Drug (MAPD), and Prescription Drug Plan (PDP).
Involved pulling data universes, writing, reviewing, packaging over 20 CAPs and managing more than 80 milestones to completion across 8 senior work streams.
Received CEO Award.
Implemented and managed a 20 member enterprise wide "swat" team responsible for deep diving into complex business processes important to our government partners, the CEO, and the Board of Directors.
Efforts included understanding top issues, cross-functional communication, and driving improvements on processes such as CTM (Government complaints), grievance, high-dollar claim volume, and customer service complaints.
Resulted in 80% reduction of defects.
Identified, developed, and designed the first Operations Balanced Scorecard listing over 50 key Medicare and Medicaid KPI's.
This allowed for proactive measurement and monitoring of the business post company sanctions.
Efforts included direct management of 10 member business analytics team that met with 10 major business segments to understand key metrics that were critical to the area.
It also included the development of a business requirement document (BRD) and coding of the metrics.
Distributed to the CEO and Board of Directors.
Successfully conducted time and motion study activities that resulted in the implementation of productivity and quality metrics across 5 different business units in Operations.
Business Analysis/Revenue Enhancement.
Directed and designed a cost-savings initiative methodology during financial downturn, which resulted in 60 unique opportunities or $130 million dollars in savings.
Position involved generating 2 cost savings idea from each business segment through interaction with area executive and budget analysis.
Efforts also included facilitating executive strategy meetings to evaluate and prioritize the cost-savings ideas.
Directed the creation of a large scale transformation testing guide that includes descriptions, sample deliverables, and best practices for all phases of testing including system, user acceptance, performance volume stress, security, regression, operational readiness, and integrated business process testing.
Six Sigma Black Belt Trainee.
Jun 2006 to Feb 2007 McKesson － Lakeland, Fl
Successfully completed 2 Six Sigma projects.
The first project included reducing defects of packages that were being shipped to wrong facilities.
Partnered with IT to create a bar code scanning system that resulted in scanning and auditing of every package before being shipped.
This resulted in a 70% reduction in defects ($6 million cost savings).
The 2nd project was an end to end analysis of the production cycle.
Standardized processes among 5 different work streams resulting in decreased work force and 30% reduction in cycle time ($4 million cost savings).
Industrial Engineering ManagerFeb 2004 to Apr 2006 United Parcel Service UPS － Lakeland, Fl
Supported the tactical and strategic operations of Central Florida's largest facility including support activities of 5 supervisors and management of over a 100 member team (union employees).
Successfully implemented productivity, quality, forecasting, training, and incentive metrics resulting in 80% increase in facility rankings (from bottom third to top 2%).
Revamped all standard operation policies and procedures to directly align with company compliance and regulatory guidelines.
Implemented daily training program of resulting in 30% increase in quality.
Partnered with IT and Operations to implement a new $20 million centralized system (work flow tool) resulting in 95% (above corporate goal) service excellence.
UPS Time Study CertificationCurrentMemberof the HCCA (Health Care Compliance Association
Masters of Science, Engineering Management2005University of South FloridaEngineering Management
Bachelor of Science, Industrial Engineering2003University of South Florida EXCELLENT EXECUTIVE REFERENCES AVAILABLE UPON REQUESTIndustrial Engineering
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