New York, New York, United States
Strategic, compliance-driven healthcare leader with 10+ years of success directing complex regulatory, clinical operations, and program development initiatives across Medicare, Medicaid (LTSS, SNP, DUAL, MMP), and Commercial lines of business. With deep subject matter expertise in audit, risk mitigation, regulatory adherence, and community health programs, I specialize in translating federal and state policies into enterprise-level operational success. From reducing ER visits by 15% through chronic condition programs to improving regulatory compliance by 60%, I deliver measurable impact across cross-functional teams. As a PMP-certified professional, I excel at building high-performing teams, driving compliance culture, and leading internal and external audits including Market Conduct Exams. I’ve supported NCQA and URAC accreditations, developed compliance monitoring tools, and served as a trusted SME for internal partners and state/federal regulators. Passionate about equity, quality, and strategy, I bring a collaborative mindset to healthcare transformation initiatives.
o Act as a gatekeeper and oversee staff who coordinate all aspects of regulatory audits o Hire and train new employees on policies, procedures, and workflows for the team. o Manage, track and report regulatory audit activities o Manage a compliance function that monitors compliance with Medicaid and Medicare legislations for business areas like HARP, CHP, Dual plans, essential plans, etc o Develop and implement policies, procedures, structures, and processes to meet regulatory audit requirements o Legal Research and Investigations o Respond to inquiries from state/federal regulators and coordinate with Legal Counsel as needed o Collect, monitor, and document changes to requirements to mitigate risks and achieve regulatory adherence o Facilitate internal and external audits and/or Market Conduct Exams o Manage escalated compliance/regulatory inquiries from either state/federal regulators or internal business partners o Conduct monitoring activities to ensure compliance o Coordinate response to Market Conduct Exam, state (Medicaid) audit inquiries or objections and Corrective Action Plans o Conduct state-specific regulatory research with ability to understand and operationalize state and federal laws
• Implementation & Operationalization: o Lead the development and implementation of new business strategies, operational processes, and policies to meet MHPAEA requirements. o Design and implement outcome measurement tools to demonstrate compliance with parity in operation. o Operationalize state and federal laws by translating regulatory language into standard operating procedures (SOPs). o Collaborate with clinical teams to align utilization management, credentialing, and network management with parity requirements. • Compliance & NQTL Analysis: o Act as the SME on MHPAEA, conducting rigorous Non-Quantitative Treatment Limitations (NQTL) comparative analyses (e.g., prior authorization, step therapy, network admission). o Collect, monitor, and document data on NQTL processes to identify deficiencies and mitigate litigation risks. o Ensure that factors used in designing NQTLs are applied comparably to MH/SUD and M/S benefits. • Monitoring & Auditing: o Support the collection of data and coordinate/create responses to MHP inquiries, audits, and exams from state/federal regulators. o Review vendor relationships to ensure third-party administrators (TPAs) provide necessary documentation for parity compliance. o Conduct ongoing operational monitoring to identify and remediate potential violations. • Stakeholder Liaison: o Act as a liaison between clinical, legal, regulatory affairs, and product teams. o Prepare and maintain detailed, technical documentation and reports for senior leadership and regulatory agencies.
o Responsible for managing a team with respect to hiring, mentoring, coaching, performance, and discipline. o Responsible for developing and executing the Internal Audit workplan for monitoring regulatory adherence for Medicare, and Medicaid programs. o Developed scope/purpose, audit methodology/tools, sampling plan, compliance/quality measures and parameters, reporting criteria and escalation pathway. o Created internal audit reports and presented findings/recommendations for leadership/committee review o Facilitated appropriate corrections, up to and including identification of training needs, development of proposals for system modifications and ensuring necessary compliance and monitoring of data. o Partnered closely with senior leadership, business teams and other third-party vendors to mitigate regulatory risk while supporting business objective o Assisted in NCQA / URAC Accreditation efforts for the organization o Drafted policies and procedures, workflows, job aids, etc to ensure compliance with regulatory and contractual requirements and respond to objections (Medicaid/state, CMS, DOH, DOI, OIG, etc.)
o Responsible for managing staff and program descriptions, work plans and evaluation processes o Responsible for Vendor Management and Oversight (data tracking and reporting) o Responsible for the development and maintenance in terms of implementation of policies, operational processes, and workflows to execute organizational strategies and to assure consistency in process application throughout the department, Medical Management/Operations o Monitored and put steps in place to ensure adherence to regulatory and non-regulatory compliance elements for HARP, FIDE, LTSS, TOC, SNP, DUAL MMPs, MLTC, CHP, EP, etc. o Performed system test and collaborated with IT to conduct system updates based on regulatory and business requirements o Collaborated and assisted with preparation for various new, or ongoing audits or applications, and implementation of various initiatives to ensure compliance with regulatory or accreditation requirements. o Designed and produced ongoing reports on programs’ progress and shared with senior leadership o Managed and provided oversight to the vendors to ensure key benchmarks were being met via consistent monitoring and auditing. o Participated in Accreditation, Regulatory and Departmental projects, including SNP Model of Care application (Approval renewal), NCQA Accreditation efforts and URAC accreditation renewal.
o Assisted with the design and pilot of a new initiative to increase enrollment for health plan o Quality outcomes oversight: NCQA accreditation, HEDIS measures and reporting, STARS, etc. o Compliance Metrics and Tools: Training, Review and data collection and presentation o Training: Provided clinical systems navigation and onsite and virtual training as needed o Developed and implemented new programs o Created staff schedule and assigned to staff their daily responsibilities o Oversaw site operations as they pertain to - facilities, maintenance, IT/AV, Alarm/security needs, supply ordering and managing inventory o Ensured adherence to P&Ps and compliance with HIPAA, PHI etc.