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Work Background
Commonwealth of MassachusettsIntegrated Care Contract Manager
Nov. 2023• Act as the primary contact for designated integrated care plans, ensuring alignment with MassHealth's contractual obligations, quality expectations, and policy objectives. Provide strategic guidance and technical support to plans to resolve issues related to member benefits, access to care, and service delivery.
• Lead performance monitoring and compliance oversight for integrated care plans, including the review and analysis of contractual reporting, capacity requirements for long-term services and supports (LTSS), and corrective action plans. Ensure readiness for CMS and internal audits involving service requests, denials, authorizations, and grievance processes.
• Collaborate with cross-functional teams across MassHealth—including OLTSS, Behavioral Health, Program Integrity, Clinical Affairs, Legal, and Finance—as well as external stakeholders such as CMS, to address complex programmatic and regulatory issues, ensuring compliance and promoting member-centered care.
• Evaluate and approve integrated care plan submissions including annual marketing and benefits materials, audit documentation, and reports. Use financial, quality, and operational data to assess performance trends and drive continuous improvement in plan operations and member outcomes.
• Serve as subject matter expert on integrated care policy, HCBS Waivers, and behavioral health initiatives. Lead readiness reviews for new and evolving programs (e.g., SCO, One Care) and facilitate workgroups focused on operational efficiencies and strategic enhancements to care coordination and program implementation.
• Foster and maintain strong relationships with internal departments, other managed care teams, state agencies, and federal partners to ensure open communication, collaboration, and shared accountability for program success.
Fallon HealthMedicare Compliance and Regulatory Affairs Associate
Jun. 2020 - Nov. 2023• Directed compliance operations for Medicare Advantage First Tier, Downstream, and Related Entities (FDRs), ensuring adherence to CMS guidelines through development of monthly communications, oversight of exclusion monitoring, and proactive resolution of compliance-related inquiries. Collaborated with Purchasing and legal teams to ensure contract language and execution remained compliant with Medicare Advantage program requirements.
• Chaired the Government Programs Vendor Oversight Committee, overseeing vendor relationships across D-SNP, SCO, ACO, and Medicare Advantage programs. Conducted comprehensive performance and compliance reviews in alignment with regulatory obligations and internal standards.
• Served as regulatory lead for CMS audit readiness across multiple product lines, including PACE and D-SNP. Coordinated documentation collection (e.g., audit universes), developed project timelines, aligned cross-functional teams across multiple states, and ensured on-time, accurate submissions. Acted as key liaison with CMS and internal stakeholders during audit cycles.
• Acted as enterprise-wide subject matter expert for Medicare and PACE regulations, delivering detailed analysis and implementation guidance for new and revised rules issued through CMS HPMS memos, Federal Register publications, and State Medicaid updates. Led cross-departmental regulatory response initiatives, including gap analysis, project planning, and workgroup facilitation to operationalize complex federal mandates.
• Designed and executed FDR compliance oversight initiatives, including development of annual compliance questionnaires, audit tools, and monitoring reports. Conducted root cause analysis and partnered with business owners to craft targeted corrective action plans and measure remediation effectiveness.
• Initiated and led regulatory change management projects in response to CMS Final Rules and other federal and state mandates. Created comprehensive project plans, monitored key milestones, managed risk, and provided progress updates to executive leadership to ensure timely and compliant implementation.
• Provided regulatory support to clinical operations and network development teams by researching statutory and regulatory requirements, interpreting policy impacts, and advising on compliance integration strategies prior to operational rollout.
• Routinely monitored, analyzed, and disseminated proposed and final federal regulations, including Medicare Advantage and PACE policy changes, to ensure department-level awareness and enterprise readiness. Maintained internal tracking systems and tools to monitor implementation status and compliance outcomes.
Point32HealthProgram Manager III, Operations Compliance
Feb. 2019 - Jun. 2020• Represented the division in regulatory interactions with agencies including OPP, NCQA, CMS, DOI, and MassHealth, addressing inquiries from providers and employer groups to ensure compliance.
• Collaborated with cross-functional teams to successfully complete the CMS Program Audit, maintaining daily compliance operations without disruption.
• Developed, implemented, and managed complex operational programs, such as the alternative format process for Public Plans, enhancing accessibility and efficiency.
• Led regulatory change management by revising policies and workflows with department leaders to maintain compliance across senior, public, and commercial health plans.
• Oversaw corrective action plans by monitoring execution and outcomes, ensuring timely resolution of compliance issues.
• Managed a comprehensive regulatory compliance program, including tracking federal/state guidance, investigating issues, conducting risk assessments, and coordinating corrective actions.
• Directed major cross-functional compliance programs, preparing materials and reports, facilitating meetings, and providing regular updates to leadership and corporate compliance teams.
• Served as the primary compliance contact and subject matter expert for Public Plans operations, identifying risks, developing mitigation strategies, and supporting implementation.
• Developed business cases and contributed to budget planning to align compliance initiatives with organizational goals and resources.
Point32HealthManager, Medicare Ops Compliance
Nov. 2017 - Feb. 2019• Managed Operations Compliance Analyst to ensure that all business needs were met. Provided performance feedback. Assisted analyst with time management to ensure that all tasks were completed on time.
• Served as subject matter expert for all regulatory questions and tasks for the Membership Operations department, including Enrollment, Premium Billing, and Revenue Reconciliation. This included Medicare Advantage, Senor Care Options and Dual Eligible Special Needs Plans.
• Conducted meetings on compliance related topics and maintained RAID logs to ensure that issues were closed both timely and within compliance standards.
• Developed new committed structures to meet department needs when the need arose, specifically for the implementation of new rules and regulations by department staff.
• Developed reports and project plans and reported up to executive leadership on progress and issues in real time. Developed corrective action plans as needed and implemented those plans to ensure the department remained in compliance.
Fallon HealthMedicare Regulatory Affairs Manager
Apr. 2016 - Nov. 2017• Conducted thorough research and detailed analysis of regulatory requirements affecting Medicare Advantage, PACE, and D-SNP products, providing strategic guidance on potential impacts and developing risk mitigation plans aligned with business goals.
• Spearheaded the full lifecycle implementation of new Part C and Part D CMS regulatory guidance by coordinating with multiple departments to revise policies, update operational processes, and manage project timelines and deliverables.
• Authored comprehensive responses to proposed and final CMS rules and Federal Register notices, ensuring clear organizational interpretation and compliance with evolving federal regulations.
• Led audit preparedness initiatives for CMS and State regulatory reviews by organizing and chairing cross-functional workgroups, developing detailed compliance plans, and managing documentation accuracy, with a focus on Fallon’s PACE program compliance.
• Acted as the primary resource for policy and procedure management by assisting various departments in drafting, reviewing, and updating compliance-related documents to reflect current regulatory standards.
• Orchestrated data gathering and documentation efforts across business units to support regulatory reviews, internal validations, and external audits, ensuring timely and accurate submission of required materials.
• Served as compliance lead for provider directory regulations, overseeing measurement and reporting activities through specialized workgroups to ensure adherence across all product lines.
• Managed complex compliance projects involving multiple stakeholders, analyzing data trends, generating detailed reports, and coordinating responses to CMS audits and inquiries to maintain regulatory alignment.
• Maintained proactive communication and relationships with regulatory agencies and industry groups to monitor regulatory changes, interpret new requirements, and incorporate best practices into company policies.
• Directed oversight and compliance monitoring of Fallon’s first tier, downstream, and related entities by conducting annual risk assessments, developing targeted compliance communications, and ensuring corrective actions were implemented effectively.
Fallon HealthMedicare Medicaid Regulatory Affairs and Reporting Manager
Dec. 2012 - Apr. 2016• Researched regulatory and benefit questions to support business requirements for the Medicare-Medicaid Plan to ensure compliance with Federal and State requirements associated with the Medicare-Medicaid Plan.
• Developed and prepared arguments in response to proposed regulatory changes associated with Medicare-Medicaid Plans
• Collaborated with individual departments to ensure correct implementation of current, proposed, and new regulations which may apply to the business area as it relates to the requirements for the Medicare-Medicaid Plan
• Reviewed and interpreted terms of all contracts and worked with business units to ensure compliance with all contractual requirements. Took a leadership role in interpreting contract documents and working closely with all departments to assure efficient operation of the plan in compliance with state, federal and other regulatory bodies.
• Received and responded to all inquiries and requests made by CMS and EOHHS in time frames and formats specified.
• Developed, initiated, and maintained policies and procedures for the general oversight of Fallon Total Care contractual requirements.
• Developed and managed the reporting process for all CMS and State reporting to ensure accurate and timely submission of all data for clinical, operational, and financial reports.
• Conducted regulatory research and provided interpretation and analysis for all business areas at Fallon Health and Fallon Total Care to ensure compliance with Federal and State requirements associated with the Medicare-Medicaid Plan. Provided analysis and dispersed research findings to upper-level management and executive leadership to ensure regulatory requirements were understood and implemented in a timely manner.
CQI: Consumer Quality InitiativesBoard Member
Jul. 2012 - Jul. 2014• Assisted the Executive Director in development of fundraising strategies.
• Monitored performance of staff and assisted Executive Director in resolving employee disputes.
• Evaluated the performance of the Executive Director on semi-annual basis; Developed annual performance goals.
• Assessed organization’s financial performance; Made recommendations for improvement.
• Attended monthly meetings and participated in committees and events as needed.
• Collaborated with other mental health organizations to reach common goals.
• Assisted Executive Director in securing grants for mental health research projects conducted by the organization.
Fallon HealthContract Manager
Oct. 2008 - Sep. 2010• Negotiated contractual arrangements, including language and pricing methodologies, for individual providers, provider groups, and hospitals. Evaluated contractual payment methodologies to determine financial risk to the insurer and provider. Interfaced between the Finance, Accounting, and Medical Economics Departments and individual sites for budget, financial reporting, and settlement arrangements.
• Identified and analyzed potential opportunities for network growth and develop the commercial, Medicaid, and Senior Care Options networks in accordance with findings and need.
• Researched, analyzed, and presented findings regarding current and potential contractual arrangements to management. Evaluated current network to determine need for additional recruitment to meet CMS regulations regarding access in new and existing areas.
• Functioned as department lead and subject matter expert for MassHealth and Senior Care Options (NaviCareSM) as it relates to contracts, network expansion, pricing methodologies, reporting, and database/system management.
• Conducted system audits to determine data integrity for reporting and reimbursement purposes, as well as to identify opportunities for savings and/or the need for new or additional department processes.
• Actively served as department representative on project teams and committees related to contracting initiatives for government programs.
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