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Work experience

Feb 2011Present

VP of Operational Performance

Gorman Health Group

Manage the Operational Performance practice area for Gorman Health Group.

  • Oversee team of Directors, Senior Consultants and Consultants
  • Lead Operational Assessments and Implementation projects
  • Assist clients in maximizing operational performance while remaining compliant with CMS.
  • Provide client training and public speaking at industry events

May 2013Dec 2014

VP of Health Plan Strategy and Compliance

  • Ensured compliance with CMS regulations for all CXP functions.
  • Oversight responsibilities for readiness and regulatory audits
  • Managed Client relationships for two of the top 10 tier health plans
  • Implemented a Retention Program for over half a million members
  • Managed disenrollment survey processes, analysis, and reporting.
Jan 2008Feb 2011

Director Product and Regulatory Mangement

Capital BlueCross

Report to Steve Russell, Vice President Medicare Operations

  • Monitor Operational Compliance with all Medicare Regulations
  • Manage the Annual renewal process to include the PBP submission, ANOC/EOC preparation and mailing and ll new year readiness activity
  • Liaison between CMS, OIG, and other regulatory entities and the plan.Facilitate all regulatory audits.
  • Ensure company oversight of MA and PDP products.
  • Lead interdepartmental teams to implement regulatory changes

Manage the dynamically changing environment of Medicare Advantage and Part D business.  Interface and facilitate process improvement and compliance with all levels of the company and operational units.

Jul 1993Jan 2008

Director of Compliance

Coventry Health Care

Coventry Health Care, 3721 TecPort Drive, PO 67103, Harrisburg, PA 17106-7103 8/93 – 01/08

Director of PDE and Business Reporting (07/07 to 01/08)

Reported to Julie May Vice President Part D (301) 775-8167

·Corporate lead to manage the PDE Error resolution process with internal Coventry staff

·Corporate lead to manage PDE process with external PDM.

·Managed corporate business reporting for Medicare products.

·Corporate lead coordinating HPMS reporting.

Compliance Director (11/06 to 06/07)

Reported to Mary Ninos, Corporate Compliance Officer

·Compliance Implementation of PFFS and new MSA product

·Document review and training for PFFS and Georgia MA plan.

·CMS Liaison for PFFS and Georgia MA plan.

·Agent Compliant management and CTM complaints

·FWA abuse committee Chair

Compliance Manager (07/06 to 11/06)

Reported to Mary Ninos, Corporate Compliance Officer

·Compliance Implementation of PFFS

·Document Review and training for PFFS and Georgia MA plan.

·CMS Liaison for PFFS and Georgia MA plan.

Business Manager Advantra/Government Programs Enrollment (11/01 to 07/06)

Reported to Mark Dawes, Vice President Financial Administration (717) 541-5928

·Responsible for the implementation of Part D for enrollment and reconciliation in both stand alone and MA.

·Handled all business aspects of Business side of Project Management for enrollment and AR deliverables for existing and new systems.

·Managed transition process for business transferred to my department to include 6 existing Medicaid plans and 3 new Medicare start up plans and two acquisitions.

·Manage Service Center department that maintains Medicare enrollment, Medicaid enrollment, and Membership reconciliation.

·Manage relationships with Nine Coventry plans health plans for Medicare and Medicaid enrollment processing

·Training to staff and Health plans on Medicare and Medicaid compliance and guidelines for enrollment and reconciliation.

On-site Project Manager for MMC project. 6/99 – 10/01

Responsible for overall project management of new software, beta testing and implementation, and process re-organization.Managing 3 consultants on site, 6 temps on site, and project day to day details through completion.

Reporting to Ruth Cheng – Business Manager (No longer with Coventry Health Care)

·Project Manager for the implementation of MMC solutions into the Medicare enrollment area to include software design, work flow and process redesign, budget management, Sr. Mgmt reporting, IS interactions for hardware support and daily/weekly status meetings.Project involved new software as well as department process reorganization.

·Worked with Central and Regional CMS office to resolve discrepancy

·Worked with MMC2020 consultants in project coordination supervising 3 staff and 4-6 temporary workers.

·Recovered more than 2.5 million dollars from 1999.

Senior Service Representative Advantra Team 2 (7/97 to 5/99)

Positional change in company restructuring from multi-management level to a flat level.

Responsible for operating in a cross functional method between enrollment and member services.

Report to Bob Beswick, General Manager (No longer with Coventry Health Care)

·Enrollment functions to include day-to-day activities, as well as trouble shooting and research.

·Working Aged classification research and submission saving the company 100,000+ a month.

·Member Services problem solving.

·Resolution of both enrollment and CMS information.

·Responsible for employer group maintenance and problem resolution.

Supervisor Advantra Enrollment (9/95 to 6/97)

Responsible for Advantra enrollment and verification staff for the Central Pennsylvania Region.

Reported to Mr. Jack Lavelle, Director Medicare Operations No longer with Coventry Health Care)

·Development and preparation of the Medicare Risk HMO Product.

·Created policies and procedures for Enrollment and Verification according to HCFA regulations.

·Responsible for the hiring and training of Enrollment and Verification staff.

·Responsible for production and processing as well as data base integrity.

·Day to day responsibilities of the enrollment department.

·Reconciliation of both enrollment and CMS information.

Promoted to Supervisor of Commercial Enrollment (12/94 - 9/95)

Responsible for the Commercial Enrollment staff for the Central Pennsylvania Region.

Reported to Mr. Tim Bastian, Director of Operations (no longer with the Coventry Health Care)

·Managed data integrity during a migration from one data base to another.

·Dealt with marketing department and employer groups to ensure satisfaction.

·Maintained the department budget and was consistently at or under budget.

·Responsible for day to day operations of the commercial enrollment department.

Member Services Representative (07/93 – 12/94)

Responsible for resolution to the incoming calls received from a Member Services queue.Responsible for tracking and trending of issues.

Reported to Nancy Wible, Service Leader

Sep 1985Jan 1992

Project Director

South Central Community Action Agency

South Central Community Action Agency (Wee Care Program)

75 Springs Avenue, Gettysburg, PA 17325(9/85 - 1/92)

Project Director (8/89-1/92)

Responsible for Administrative functions

Reported to Ms. Jean Odom, Executive Director SCCAP (717) 334-7634 ext. 124

·Responsible for Budget (both in raising funds and meeting expenses)

·CCFP contract and compliance

·Title XX contract and compliance.

·DPW licensing and compliance

·Staff hiring, evaluations, training and terminations.

·Public relations to include publicity, public speaking, creation of ads, brochures, and public releases


Medicaid Enrollment and Reconciliation
Management and Integration of multiple state Medicaid plans into a Medicaid enrollment  service center.  Maintained strong plan engagement.  Served as liaison with each state regulatory area concerning all Medicaid enrollment and reconciliation issues.
Medicare Advantage and Part D Operations
All areas of Medicare Advantage and Part D Operations Service Area Expansions PBP Benefit Entry and Submission Document creation, review, and submission to CMS Enrollment Operations of multiple health plans and products Reconciliation Activities to include Risk Adjusters, PDE, Enrollment Discrepancies and LIS data MSP Process Management Customers Service and Telephonic standards and quality management Medicare STAR review and focused improvement CMS Grievance and Appeals Processes FWA committee management and chair Project Plan creation and management for CMS annual and daily changes Integration of New Health plans obtained through acquisition or consolidation
Medicare Compliance
Medicare Compliance is more than knowing the regulations.  Facilitating change in real life situations is necessary to make a program successful.  I am able to engage operational areas at all levels to bring about compliant change within my organization.  This occurs through: Understandable and meaningful training and knowledge exchange All levels of operational readiness review to CMS audit guide or regulation requirements Up to the minute engagement of the ever changing CMS requirements Audit management from initial notification through any necessary Corrective Action Plans Understanding of the "why" of the regulations.



BS in Health Services Administration

Upper Iowa University

AA in Business Studies



Mark Dawes

Miriam Duckworth



Engaged and knowlegable Management of Medicare Advantage and Part D business.  Integration of the Compliance and Business needs of companies that are engaged in Medicare products is my top priority.  I know how to engage staff and "translate" the unique regulatory requirements that are critical to Medicare business.  I can work with in company culture and structure to ensure staff have the knowledge they need to have a high quality and compliant Medicare Advantage and Part D program.

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