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Click here or scroll down to respond to this candidateCandidate's Name
Street Address Grand Lakes Drive EastJacksonville, Florida Street Address
PHONE NUMBER AVAILABLE (home)/ PHONE NUMBER AVAILABLE (cell)EMAIL AVAILABLEQUALIFICATIONSExperience in the insurance/benefits industry has given me a solid understanding of numerous types of benefit plans, thorough knowledge of state and federal laws and regulations affecting benefit plans, strong research and writing skills, and familiarity with medical terminology and developments.Highly productive individual with excellent analytical and organizational abilities and proficiency in a variety of computer applications, including MS Windows, MS Office, Google Chrome, Mozilla Firefox, Workfront, and ProofHQ. Outstanding written and oral communications skills.Special expertise in the areas of Original Medicare, Medicare Advantage and Medicare Part D; Managed Care, Cafeteria, and Consumer-Directed Healthcare Plans; and the Affordable Care Act.Strong interest in health care policy and outcomes and in communicating with members to help them better understand the complex health care system they must navigate. EXPERIENCEMedicare Regulatory Florida Blue (Blue Cross and Blue Shield of Florida), Jacksonville, Florida Specialist (Medicare Regulatory Operations Team, November 2013 August 2016; Medicare Materials Review Team, August 2016 September 2020)Reviewed all types of marketing materials and communications produced for Medicare beneficiaries (including advertising pieces, enrollment and informational scripts, Florida Blues Medicare website, social media posts, Summaries of Benefits, Evidence of Coverage books, enrollment forms, formularies, provider directories, enrollment guides, new-member welcome kits, grievance and appeals letters, and enrollment and billing letters) to ensure they complied with the Medicare Communications and Marketing Guidelines, applicable federal regulations, and Florida Blue policies and procedures. Indicated needed changes to materials to make them compliant, accurate, grammatically correct, and stylistically appropriate.Conducted training sessions on the Medicare Communications and Marketing Guidelines and the overall material review and approval process as needed for internal clients such as Marketing and Enterprise Communications.As needed, assisted the Medicare Regulatory Operations Team in producing formulary and provider directory documents and Summaries of Benefits.Uploaded materials that were required to be filed with the Centers for Medicare & Medicaid Services (CMS) through CMSs Health Plan Management System (HPMS) marketing module. For materials that were disapproved, worked with our CMS plan manager or materials reviewer to make the changes needed to gain approval.Researched and analyzed federal and state statutes, regulations and guidance to provide compliance advice on a wide range of topics to senior management and others throughout the company.Actively participated in yearly meetings to develop strategy, benefits and pricing for annual Parts C and D bids, which are submitted to CMS each June. Also participated in the vendor-selection process for implementation of benefits such as transportation.Candidate's Name -Page 2Compliance Specialist Florida Blue (Blue Cross and Blue Shield of Florida), Jacksonville, Florida September 2010 November 2013Monitored HPMS, Medicare Advantage Prescription Drug (MAPD) Help Desk and Coverage Update memo releases; analyzed and interpreted the releases; distributed them to appropriate functional areas with required assignments; and tracked progress of assignments. Conducted review sessions after major releases (e.g., Medicare Communications and Marketing Guidelines, MAPD Eligibility Guidelines, Call Letter) to compile questions and comments for submission to CMS.Participated regularly in Blue Cross and Blue Shield Association and America's Health Insurance Plans calls on topics involving Florida Blues Medicare business, such as the annual Call Letter, Marketing Guidelines, and new federal regulations.Participated in biweekly regulatory calls with Prime Therapeutics, Florida Blues pharmacy benefit manager, and other Blues plans to discuss requirements related Medicare Part D.Participated in Business Ethics, Integrity and Compliance's monthly plan manager call with CMS to discuss plan operational and compliance issues.Researched and analyzed federal and state statutes, regulations, and guidance, often on an ad hoc basis, for many areas within Florida Blue. Interacted frequently with senior management to provide compliance advice.Reviewed marketing materials and communications targeted to Medicare beneficiaries to ensure compliance with CMS regulations and guidance.Maintained the corporate policies and procedures website in Stellent.Served as a point of contact for CMS's MARx eligibility system, granting, renewing, and terminating MARx access as needed.Proctored agent sales presentations throughout Florida to ensure agents' presentations complied with Florida Blue and CMS requirements. Senior Contract Blue Cross and Blue Shield of Florida, Jacksonville, Florida Administration Analyst May 2006 - September 2010Prepared all required Medicare Advantage and Part D member materials, such as the Summary of Benefits, Annual Notice of Changes, Evidence of Coverage, pharmacy/provider directories and formulary documents for all our Medicare plans, both individual and group.Reviewed a variety of other Medicare marketing materials and communications and filed them with CMS as needed.Conducted frequent research into Medicare rules and regulations. Account Manager Harden and Associates, Jacksonville, Florida January 2005 November 2005Facilitated internal and external meetings to determine clients benefit program goals and prepared appropriate requests for proposals for submission to insurance carriers and third-party administrators.Evaluated benefit proposals received to determine which most closely matched clients needs.Negotiated with carrier/third-party administrator representatives to obtain optimal pricing for benefit plans and services.Prepared monthly benefit compliance updates for Harden staff and clients.Researched benefits-related legal and legislative developments (e.g., Medicare Part D) and proposed actions to ensure client compliance with new Candidate's Name -Page 3requirements.Served as client liaison with insurance carriers to resolve day-to-day issues related to claims, eligibility, plan coverage, and compliance. Compliance Manager/ Medcom Services, Inc., Jacksonville, Florida Operations Specialist 2001 2004Carried out extensive research into Cafeteria Plan design, Health Reimbursement Arrangements (HRAs), and Health Savings Accounts (HSAs) to assist internal customers (Medcoms marketing, claims, and customer service departments) and external customers (brokers, consultants, and plan sponsors).Prepared legally compliant plan documents and summary plan descriptions for self-funded medical, dental, and vision plans and for Cafeteria Plans.Performed nondiscrimination testing for Section 125 (Flex) Plans.Conducted enrollment meetings for both health benefit plans and Cafeteria Plans for local and out-of-town clients.Conducted internal and external training classes on subjects such as federal claims regulations, HIPAA privacy provisions, COBRA, HSAs, coverage of over- the-counter medicines under FSAs, and the content of plan documents/summary plan descriptions.Coordinated Medcoms participation in Shands Jacksonvilles benefits fair.Composed all claims system letters (student status, pre-existing conditions, accident information, etc.).Served as legal and coverage-issue resource for Medcoms staff and clients on a wide variety of benefits issues, often on an impromptu basis.Acted as primary contact at Medcom for Shands Jacksonvilles benefits staff on account-related issues.Assumed responsibility for researching pharmacy benefit managers and selecting a new one for two of Medcoms key clients. Also assisted in implementing the new contract once concluded.Technical Analyst/ Employers Mutual, Inc., Jacksonville, Florida Compliance Specialist 1995 2000Tracked federal and state regulatory requirements and ensured that all plans complied with them.Produced all client summary plan descriptions and plan amendments.Researched and complied with various state third-party administrator licensing requirements according to business needs.Researched and analyzed numerous provider pricing agreements and benefit plans to build claim system logic to meet the specifications of those agreements and plans.Worked with claims department to troubleshoot problem claims using system knowledge.Served as co-manager of a project at a large PHO to build all aspects of provider pricing on a new claims system in preparation for a system conversion. EDUCATION Bachelor of Arts Degree, College of William and Mary, Williamsburg, Virginia(major in French language and literature, minor in political science). Completed course work for Master of Arts Degree in political science at the University of Virginia, Charlottesville, Virginia. Speak, read, and write French fluently. |
