Experience

ATRIO Health Plans

• United States
• Insurance
• 1 - 100 Employee

• Compliance Manager

  • Jun 2023 - Present



ApexHealth

• United States
• Insurance
• 1 - 100 Employee

• Sr Medicare Compliance Specialist

  • Mar 2022 - Jun 2023



Aetna, a CVS Health Company

• United States
• Wellness and Fitness Services
• 700 & Above Employee

• Regulatory Reporting Project Manager (Remote)

  • Dec 2018 - Jan 2022

  Verified compliance and submission with new regulatory requirements and satisfied regulation in timely manner with state’s regulator by collaborating with business owners. Tracked all new legislation within team and guaranteed fulfilment of metrics. Supervised triage, distribution, and validation of New Legislation. Encouraged collaboration among business owners. Communicated directly to States Department of insurance to executives. Led inventory and submission of ~1400+ periodic regulatory reports across 14 states and 25 entities. Minimized risks by proactively determining key areas of risk within reporting and recommending enhancements. Improved ABX of large scale National Annual Advertisement Certification of all required states. Attained ABX White belt and enhanced basic concepts of Six Sigma. Show less

• Medicare Part D Sr. Compliance Manager (Remote)

  • Jun 2014 - Dec 2018

  Managed Medicare FDR sales partner program. Monitored distribution and validation of regulatory alerts, performed auditing, assessed risks, and drove documentation, such as policies and procedures to demonstrate effective compliance program. Enabled regulatory compliance with federal laws and CMS guidance by supporting in internal/external audits. Conducted audit and events on FDR from compliance program effectiveness (CPE) and performance perspective. Maintained compliance program, including risk assessment, auditing and monitoring, effective communication, and training. Validated and deployed any and all regulatory guidance policy updates federal/state with business partners. Delivered guidance and mentorship to new employees within team during on- boarding process. Built and managed collaborative relationships with business partners; allowing for quicker termination to areas of risk and mitigating financial impact to organization. Mentored audit team via CMS Program Audit and CMS Tracer. Developed and deployed 2019 FDR sales partner risk assessment scoring methodology to attain extreme differentiation. Involved in presentation of Aetna’s compliance program effectiveness (CPE) to CMS; recognized as industry leader. Headed compliance business process reviews and corrective actions. Improved current working knowledge and expertise in Federal Compliance with strong focusing on Medicare and Medicare/Medicaid requirements. Show less

• Medicare Part D Compliance Manager (Remote)

  • Jul 2012 - Jun 2014

  Led Aetna’s Medicare Part D Rejected Claims Team. This team was developed as a response to CMS sanctions post program audit. I managed Four direct reports in this role. Directed coordination of multiple teams during CMS audit functions, covering preparation, presentation, and resolution of corrective action plans. Partnered with executives, leaders, and third-party vendors to steer assessment and resolution of significant financial as well as member impact issues. Provided cross functional assistance to key operations projects. Supported management for revising and analyzing daily claims dashboard. Determined patterns within claims inventory and collaborated with claims leadership as well as claims TPA for elimination. Led provider calls by serving as claims SME. Minimized risk exposure by delivering strategic guidance to business leaders and auditors to ensure Medicare Compliance and CMS. Recognized and documented benefits, costs, and risks associated with business decisions by engaging with team, management, and self-directed. Created policies and procedures around new HPMS memos and guidance through collaboration with business partners and stakeholders. Show less

• Patient Managment Consultant (Remote)

  • Jul 2010 - Jul 2012

  Coordinated the flow of patients through the facility, surgery, rehabilitation and discharge to home.

• Certified Pharmacy Technician Coverage Determination

  • Nov 2003 - Jul 2010

  Essential Duties and Responsibilities1. Initiate and coordinate prior authorization requests in the automated prior authorization system.2. Act as a liaison between the Clinical Department and members, providers, pharmacies, and internaldepartments and respond to inquiries regarding status of prior authorization requests.3. Assist with internal and external reporting requests and summarize internal program statistics.4. Execute reporting matrix of key prior authorization metrics for presentation to department andmanagement upon request.5. Maintain prior authorization management solution, including:a. Interpretation and application of prior authorization guideline revisions.b. Configuration and quality assurance of clinical criteria, decision scenarios, and other elements.c. Software release testing.d. Collateral revisions.e. Development and maintenance of notification templates in compliance with client plan languageand other regulatory requirements.6. Compare prescription claims data against requested parameters and summarize/present results orrecommendations.7. Develop and maintain departmental desk-level procedures, training materials, and relateddocumentation. Train on prior authorization management system updates as directed.8. Perform other duties as assigned. Show less



Walgreens

• United States
• Retail
• 700 & Above Employee

• Pharmacy Technician

  • Jan 2002 - Jan 2003

  Supported pharmacological services by assembling, stocking and distributing medications Maintaining records by recording and filing the prescriptions and orders of Physicians Sorting, stocking and labeling medications and monitoring inventory Responding to the requests of patients and healthcare providers, answering their questions and referring various inquiries to the Pharmacist Complying with rules, regulations and procedures to help maintain a clean and safe pharmacy, such as by sterilizing equipment and surfaces Processing prescriptions electronically and ensuring all information is accurate and complete Generating revenues by recording, calculating and issuing charges Handled administrative tasks such as record-keeping as assigned by a Physician or facility manager Show less



Wilsons Leather

• United States
• Retail
• 300 - 400 Employee

• Retail Manager

  • Mar 1997 - Jan 2002

  Manager of several stores in the San Diego and La Hoya areas of Southern California. Responsible for hiring, scheduling, audits, reporting. Manager of several stores in the San Diego and La Hoya areas of Southern California. Responsible for hiring, scheduling, audits, reporting.



US Copeland-FFG-25

• Greater San Diego Area

• Us Navy

  • Jan 1993 - Mar 1997

  Drug interdiction Drug interdiction