Angel Tirado-Morales, CHC
Chief Compliance Officer at MMM of Florida, Inc.- Claim this Profile
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Bio
Credentials
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Certified in Healthcare Compliance (CHC)
Health Care Compliance AssociationAug, 2021- Nov, 2024
Experience
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MMM of Florida, Inc.
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United States
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Insurance
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1 - 100 Employee
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Chief Compliance Officer
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Jun 2019 - Present
With a track record as a successful Chief Compliance Officer, I possess a history of advising on best practices for regulatory agencies, health care facilities, and managed care organizations. Among my many talents is an innate ability to lead teams in seamlessly cultivating strong business relationships, identifying compliance risk, and generate innovative solutions. My reputation as a goal-oriented project champion with expertise in risk management, growth and profitability, product management, and public health policy, is demonstrated in my current role. Show less
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Guildnet -Lighthouse Guild
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Greater New York City Area
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AVP, Medicare Services
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May 2016 - Present
As a professional with Guildnet Lighthouse Guild, I regulated numerous quality interventions with Medical Management teams, which improved CAHPS, QIP, MOC goals, and other metrics. I served as a Healthplan Lead for Medicare BID processes and as a key participant in the Fiscal Management of all Medicare plan functions. I cultivated improvement strategies of data collection quality for FIDA Quality Withhold Metrics that resulted in receiving full quality withhold dollars to the plan for two consecutive years. Moreover, I revamped the Medicare BID process, expanding the participation to additional key departments and enhancing the allocation of Medicare dollars. Some key achievements in this role include: • Accomplished a 100% increase in HEDIS results for Medicare products during the first year of employment. • Successfully enhanced Call Center metrics by 400% through the restructuring, redefining, and aligning of performance metrics to adhere to CMS performance metrics. • Streamlined program planning, policy development, and operation of Medicare plan functions, programs, and activities for a Dual SNP Medicare product and New York State MMP dual demo program. • Launched multiple training and educational modules for Customer Service and Case Management staff regarding the purpose and logic of metrics, which permitted monthly performance metrics. • Instrumental liaison for government agencies, regulatory bodies, trade associations, and delegated entities. Show less
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Elderplan Inc
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United States
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Hospitals and Health Care
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100 - 200 Employee
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Director
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Oct 2013 - Jan 2016
During my time with Elderplan, I orchestrated and instituted action plans linked to investigations, Prescription Drug Claims or Events (PDE), Quality of Improvement Programs, and Model of Care Implementation. I directed investigations of regulatory agency citations, claims reimbursement, member/participant grievances, regulatory compliance, and provider complaints. Lastly, I chaired the operational implementation for FIDA (MMP) product while leading benefit configuration, product development, operational structure, and continuous process improvements for Medicare Advantage products, including two D-SNPs, one MMP, and four MAPD products. Some key achievements in this role include: • Pioneered a fully operational implementation of the FIDA program, which included ambitious clinical management directives and structure to build a new reporting statutory structure. Show less
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MetroPlusHealth
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Hospitals and Health Care
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700 & Above Employee
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Director of Medicare Operations
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Apr 2011 - Sep 2013
With this organization, I introduced new monitoring indicators and audit protocols for PBM delegated activities, including EOB review, TROOP Accumulations, Transition Fill 4rx, PDE, Member refunds, and FIR. I served as a Product Manager, directing Medicare Advantage and Medicare Part D lines of business. Acted as an Account Manager and Senior Contact with CMS and New York State DOH. Finally, I regulated process implementation and improvement and planned education for regulatory body reporting/communications, Prescription Drug Claims or Events (PDE), regulatory compliance, Model of Care, appeals and grievances, regulatory agency citations, and claims reimbursement. Some key achievements in this role include: • Slashed MMR membership dollar variances for CY 2012 by 300% through the identification of discrepancies and reconciling of CMS reports with member details. • Championed the leadership of the 2013 BID process that defined benefit packages for coverage based on actuarial information and marketing needs, negotiation of key additional benefits, and delivery of more competitive products. • Executed the 2013 Onsite Model of Care audit, achieving the third highest health plan score in a nationwide Medicare Advantage audit and the Medicare Full Scale Audit with a rating of 10/13. • Maximized star ratings quality standards by collaborating with the Clinical Department and New York DOH on DSNP's contractual-related regulations. • Eliminated manual data collection by heading the implementation of process improvements for CMS Reporting Requirement Data Collection and Submission to define and automate reporting metrics. Show less
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Triple-S, Inc
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Puerto Rico
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Compliance Officer
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Feb 2005 - Apr 2011
While working at Triple-S, Inc., I presided as a Senior Management Team Member handling the implementation of Medicare Advantage, Corporate Compliance for Medicare, and Medicare Part D for inclusion in the Medicare Advantage market. I authored a standard of conduct manual to guarantee compliance with both federal and commonwealth healthcare requirements. Furthermore, I directed process implementation, action plans, and investigations for regulatory compliance, subscriber complaints/grievances, claims reimbursement, Quality Improvement Programs, provider and regulatory agency citations, Prescription Drug Claims or Events (PDE), and Model of Care Implementation. Some key achievements in this role include: • Spearheaded the creation and implementation of a Corporate Compliance Program and auditing program to achieve increasingly complex state and federal regulatory requirements for Medicare Advantage and Medicare Part D. • Composed a scope of responsibilities and facilitated training for three direct reports in the Compliance Division. Show less
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Education
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2001 - 2004
New York University, Robert F. Wagner Graduate School of Public Service
Master of Public Health Administration, Health Policy and Management -
1994 - 1999
University of New Hampshire
Bachelor's degree, Health/Health Care Administration/Management
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