Experience

Simply Healthcare Plans

• United States
• Insurance
• 200 - 300 Employee

• Program Director, Florida Healthy Kids

  • Jan 2023 - Present



Lee Health

• United States
• Hospitals and Health Care
• 700 & Above Employee

• Executive Director Health Plan Operations

  • Aug 2021 - Dec 2022

  • Develop and implement strategic and tactical plans to ensure further growth and development of the business unit and ensure positive financial results. • Develop and implement departmental policies and procedures. • Collaborate with Board of Managers to identify, create and implement strategic plans to actualize business objectives. • Oversee Marketing Department and its activities. Collaborate with Marketing vendor to ensure regulatory requirements are met. • Oversee and… Show more • Develop and implement strategic and tactical plans to ensure further growth and development of the business unit and ensure positive financial results. • Develop and implement departmental policies and procedures. • Collaborate with Board of Managers to identify, create and implement strategic plans to actualize business objectives. • Oversee Marketing Department and its activities. Collaborate with Marketing vendor to ensure regulatory requirements are met. • Oversee and collaborate and implement regulatory requirements with business partners as policy changes occur. • Oversee development and execution of operating plans, including employee development, organization goals, and member and provider relations goals. • Oversee operations and ensure employees and business partners comply with regulatory and legal requirements. • Oversee Provider Relations Department and ensure provider issues are resolved timely. • Oversee Credentialing process to ensure updates are made timely according to regulatory requirements. • Provide guidance to Provider Relations staff on problem prevention and resolution. • Establish criteria for measuring and assessing the success/performance of each component of operation. • Ensure appropriate provider network is developed and maintained. • Develop effective relationships with key stakeholders to educate providers and consumers on necessary topics. • Develop effective relationships with industry regulators and other relevant parties. • Develop and establish operational mission statements, philosophy, policies, goals, objectives and strategy. • Identify potential risks and opportunities within the organization to protect business interests • Provide management all necessary contractual requirement information regarding state and federal regulatory agencies. • Implement and lead a structured Executive Committee and Operations Committee

• Director Health Plan Operations

  • Mar 2020 - Aug 2021



UnitedHealth Group

• Hospitals and Health Care
• 700 & Above Employee

• Director of Claims and Appeals, Specialty Operations

  • Nov 2016 - Mar 2020

  • Operational responsibilities include oversight of over 200 employees within Claims and Appeals stateside and India • Provide general claims and appeals support to teams in reviewing, researching, investigating, negotiating, processing claims/appeals • Evaluate operation to identify opportunities to reduce operating costs. Contributed to 9% towards savings in 2018 and 7.9% in 2019 • Achieved the following performance metrics during my time • overall accuracy rate increase of 15%… Show more • Operational responsibilities include oversight of over 200 employees within Claims and Appeals stateside and India • Provide general claims and appeals support to teams in reviewing, researching, investigating, negotiating, processing claims/appeals • Evaluate operation to identify opportunities to reduce operating costs. Contributed to 9% towards savings in 2018 and 7.9% in 2019 • Achieved the following performance metrics during my time • overall accuracy rate increase of 15% within Appeals & Grievances • dental claims auto-adjudication rate increase of 9.8% • increased overall performance on turnaround time for both Claims and Appeals metrics • Employee Engagement increase of 11 points, 2019 at 77% • Manager Effectiveness Index increase of 17 points, 2019 at 91% • Prepare operations, people, leaders and infrastructure to support growth • Drive consistent performance metrics and execute projects, deliverables and initiatives • Prepare and deliver presentations to and foster relationships with critical stakeholders • Nominated/participated in the Women in Leadership program from 2018-2019 Show less



Cigna-HealthSpring

• Director of Government Programs

  • Apr 2010 - Jan 2015

  Miami, Florida • Responsible for compliance oversight for the Leon Medical Centers Health Plans market of Cigna-HealthSpring • Monitor and oversight of state and federal regulation changes as well as the implementation of new legislation • Work closely with business units on the development of policy and provide regulatory guidance as well as manage the contractual and regulatory relationship with governing agencies • Responsible for completing the annual audit schedule based on annual risk… Show more • Responsible for compliance oversight for the Leon Medical Centers Health Plans market of Cigna-HealthSpring • Monitor and oversight of state and federal regulation changes as well as the implementation of new legislation • Work closely with business units on the development of policy and provide regulatory guidance as well as manage the contractual and regulatory relationship with governing agencies • Responsible for completing the annual audit schedule based on annual risk assessment, drafting audit report and communicating results to management team • Audit operational areas such as G&A, Claims, Enrollment, Member Services, UM, etc. to ensure compliance with state and/or federal regulations and contract requirements • Serve as subject matter expert for Compliance liaison as it pertained to internal and external audits • Responsible for overall coordination, status reporting and stability of complex and cross-functional project oriented work efforts • Establish and implement project management processes and methodologies for multiple projects simultaneously • Responsible for creating and delivering annual marketing materials inclusive of the ANOC/EOC, Summary of Benefits, Provider & Pharmacy Directory and Formulary as well as the plans website Show less



UnitedHealth Group

• Hospitals and Health Care
• 700 & Above Employee

• Sr. Employer Installation Administrator

  • Dec 2007 - Apr 2010

  Miami, FL • Generate a Paid Time Off (PTO) Policy & Procedure for the Key Accounts Case Installation and the Implementation Management Organizations of UnitedHealth Group • Establish set thresholds within each Department of which equal to about 700 employees • Keep track of each employees scheduled time away from work as well as the unplanned time away from work • Roll out Mymetrics – a database to record processing and non-processing time • Generate reports for staffing model and occupancy… Show more • Generate a Paid Time Off (PTO) Policy & Procedure for the Key Accounts Case Installation and the Implementation Management Organizations of UnitedHealth Group • Establish set thresholds within each Department of which equal to about 700 employees • Keep track of each employees scheduled time away from work as well as the unplanned time away from work • Roll out Mymetrics – a database to record processing and non-processing time • Generate reports for staffing model and occupancy. Any others as needed • Keep track of all attritions and reallocations within Departments • Support all areas of Key Accounts during Open Enrollment Show less



Neighborhood Health Partnership, Inc

• Grievance & Appeals Manager

  • Aug 2005 - Dec 2007

  Miami FL • Responsible for reviewing results of all grievance and appeals investigations. Ensure the handling, preparation, and disposition of the case is compliant with contractual obligations, regulatory standards, and internal policies and procedures • Prepare internal and regulatory audits, including, but not limited to; case review, legislative review, and updating policies and procedures • Responsible for case preparation of grievances/appeals that are elevated to the Subscriber Assistance… Show more • Responsible for reviewing results of all grievance and appeals investigations. Ensure the handling, preparation, and disposition of the case is compliant with contractual obligations, regulatory standards, and internal policies and procedures • Prepare internal and regulatory audits, including, but not limited to; case review, legislative review, and updating policies and procedures • Responsible for case preparation of grievances/appeals that are elevated to the Subscriber Assistance Panel, Administrative Law Judge hearings, or claim related litigation • Chair the Subscriber Assistance Panel hearings, Administrative Law Judge hearings, Grievance Committee hearings and Quarterly Overturn Committee • Compile logs, reports, files, and other data that may be required by the plan or regulatory agencies with respect to the grievance and appeals process • Effectively communicate and work with members, providers, state and federal regulators, peer review organizations, and all departments within the organization in order to resolve and close case files • Identify systemic organizational issues and execute improvements Show less



Neighborhood Health Partnership, Inc.

• Government Programs Analyst

  • May 2002 - Aug 2005

  Miami, FL • Conduct internal audits of operational areas handling Medicare business following the Medicare Monitoring Guide. Prepare summary reports of findings • Assist in the preparation of external regulatory site visits • Identify potential risk areas and opportunities for improvement with the day to day operations of the internal departments • Assign and implement corrective action plans for any department who is deficient with regulatory standards (below 95%) • Produce and send… Show more • Conduct internal audits of operational areas handling Medicare business following the Medicare Monitoring Guide. Prepare summary reports of findings • Assist in the preparation of external regulatory site visits • Identify potential risk areas and opportunities for improvement with the day to day operations of the internal departments • Assign and implement corrective action plans for any department who is deficient with regulatory standards (below 95%) • Produce and send regulatory reports to CMS and DFS • File product materials with CMS and DFS ensuring all regulatory requirements are met • Monitor Government Programs calendar and report grid for items that need to be filed. Monitor regulatory reports that are scheduled for submission • Participate in the Government Programs Committee and Compliance Task Force • Research compliance topics and communicate answers to plan respective areas. Research and respond to the regulatory agencies as it relates to member complaints.

• Grievance & Appeals Administrator

  • Apr 2001 - May 2002

  Miami, FL • Conduct research, perform detailed investigations and respond to member grievance and appeals for Medicare, Medicaid, and Commercial members, in accordance with applicable (CMS, IRE, AHCA, DFS) regulatory requirement, standards (NCQA), and departmental policies and procedures • Prepare a case file for each grievance and appeal received • Ensure that the entire grievance and appeals process is completed in accordance with regulatory timeframes and standards as well as departmental… Show more • Conduct research, perform detailed investigations and respond to member grievance and appeals for Medicare, Medicaid, and Commercial members, in accordance with applicable (CMS, IRE, AHCA, DFS) regulatory requirement, standards (NCQA), and departmental policies and procedures • Prepare a case file for each grievance and appeal received • Ensure that the entire grievance and appeals process is completed in accordance with regulatory timeframes and standards as well as departmental policies and procedures • Effectively communicate and work with members, providers, state and federal regulators, peer review organizations, and all departments within the organization in order to resolve and close case files within timeframes • Review results of grievance/appeal investigations to ensure that the decision made is compliant with contractual obligations, regulatory standards, and internal policies and procedures. • The ability to meet and/or exceed departmental quality and production standards; and assist other members of the grievance and appeals department when needed