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Health Insurance

Location:
Scottsdale, Arizona, United States
Salary:
125,000
Posted:
August 09, 2019

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Resume:

CARLA KOT

**** *. ****** *** *****

Scottsdale, AZ 85260

480-***-**** (Cell)

ac91fy@r.postjobfree.com

SUMMARY OF QUALIFICATIONS

A professional with experience in the private and public legal and business sectors who thrives on challenge and change.

An experienced executive who is a strategic thinker and uses excellent judgment to reduce risks and to resolve organizational challenges.

A team player with the ability to build consensus by identifying and utilizing the best qualities of staff.

An organized and efficient counsel with the ability to prioritize, organize and complete many projects successfully and manage all goals to an excellent result.

SKILLS

Healthcare Law Expert with experience in legal and operational issues involving carriers, health plans, providers, facilities and billing companies.

Well-versed in the Affordable Care Act, HIPAA, Stark, Self-Referral, ERISA, In- and Out-of-network coding and billing, Grievances and Appeals, Medicare, Medicaid and Corrective Action Plans.

Extensive experience drafting and revising contracts of all types, business associates agreements, non-disclosure agreements, explanations of coverage, summaries of benefits, coverage determinations, compliance manuals and policies and procedures.

Compliance Expert who has written and developed Compliance Plans, manuals, policies and procedures as well as performed training for all levels of employees.

Ability to investigate and audit organizational challenges by being a creative thinker who can troubleshoot to resolve non-compliant issues and develop business solutions.

EDUCATION

J.D., DePaul University, College of Law, Chicago, IL

B.A., Political Science, University of Wisconsin-Milwaukee

BAR ADMISSIONS

Wisconsin (Retired)

Illinois (Retired)

Arizona (Active)

ASSOCIATIONS

American Health Lawyers Association

Arizona State Bar Association

Arizona Life and Disability Insurance Guaranty Fund Board (2013 to 2016)

Certification in Healthcare Compliance (Healthcare Compliance Association) (Retired)

EXPERIENCE

Legility Present

ATTORNEY(Contractor)

Provide in-house legal services on a contracted basis for outside organizations

Work with other assigned contractors to complete projects as assigned

Lumen Legal Present

ATTORNEY(Contractor)

Provide in-house legal services to outside organizations

Work with other assigned contractors to complete projects as assigned

Legal Research Center, Inc. Present

RESEARCH ATTORNEY (Contracted)

Perform Legal Research for Organization’s Clients as assigned

Work with Research team to complete Health Law and other projects as assigned

Work with other assigned contractors in fifty state surveys of health law issues and requirements for medical practice

Arizona Department of Economic Security April 10, 2017 to October 2017

CHIEF HEARING OFFICER

Supervision of a team of Administrative Law Judges and support staff

Member of the Appellate Services management team

Extensive knowledge of federal and state laws and regulations, departmental policy and precedential decisions for more than 45 different programs administered by DES;

Provide input on policy issues and advance policies set forth by the administration

Responsible for interacting with members of the public providing information about the hearing process and other information upon request

Conduct follow-up to assure that hearing decisions are implemented

Special projects as assigned

AllianceMed, LLC August 2015 to November 2015

GENERAL COUNSEL

Develop strategy for collection of claims for out of network providers

Provide legal opinions on all business and healthcare matters

Advise on Human Relations issues

Develop Compliance Program for Medicare claims

Advise CEO on business strategy

Review physician practices for Stark and Anti-Kickback violations

Oversight of suits filed by the business

United Healthcare August 2012 to February 2015

ASSOCIATE GENERAL COUNSEL, Regulatory Affairs State Lead for Arizona, Idaho and Utah, Legal Counsel for United Healthcare Community Plan for New Mexico, Arizona United Healthcare Community Plan for Children’s Rehabilitative Services

Regulatory liaison to the Departments of Insurance for the States of Arizona, Idaho and Utah

Work with Health Plans in each state to comply with regulatory requirements and accomplish business goals

Legal research on all health law issues as well as presenting these findings to executives and business units

Manage projects for the Affordable Care Act and its requirements

Present quarterly reports to the Boards of Arizona health plans

Member of United Commercial Arizona Executive Leadership Team

Member of Commercial Affordability Team

Provide legal opinions and guidance for New Mexico Medicaid Plan.

Member of New Mexico Medicaid Plan Executive Leadership Team.

Review contracts for compliance with requirements for organization

Represent Medicaid Plan in Corrective Action Plan Responses and contacts with State.

Member of group called Common Resource Pool consisting of eight attorneys with special experience and expertise who can be called on to assist with complicated legal matters throughout the organization.

Track and analyze legislation that impacts the business

Consult with sales staff to assure compliant behavior

SENIOR COMPLIANCE OFFICER

Southwest Catholic Health Network

Mercy Care Advantage HMO August 2011 to May 2012

Compliance and Privacy Officer for Organization

Plan and Implement Compliance Program

Interface and Reporting to CMS

Conduct Audits and Monitoring for Organization Operations

Draft Compliance Plan and Compliance Manual

Revise and draft all Policies and Procedures

ASSISTANT DIRECTOR OF CONTRACTS AND COMPLIANCE

Healthcare Group of Arizona February 2006 to August 2011

Draft all Group Service Agreements and Member Handbooks

Draft and revise all Vendor Contracts

Draft and revise all Policies and Procedures

Provide Benefit and Coverage interpretations and Interface with Medical Management,

Negotiate and Draft Letters of Agreement with Facilities and Providers

Compliance and Privacy Officer and Compliance Training

Created and Supervised Eligibility Program for Membership

Represent Organization throughout Appeal Process and at State Fair Hearings

Respond to Complaints and Inquiries from Members and Governor’s Office concerning all aspects of Operations

Involved in decision and policy-making in all aspects of Operations

Involved in RFPs for the Organization

Organization’s legal counsel on all aspects of Healthcare Reform; drafted Healthcare Reform compliant Benefit Plan and Group Service Agreement.

SENIOR INSURANCE ANALYST LEGAL ANALYST

Arizona Department of Insurance

Reviewed and Approved document and advertising filings for the Life and Health Division for major commercial carriers

Provided Legal Opinions on Insurance Issues to Organization

Involved in Market Conduct Exams

Represented the Director on the Long Term Care Council

Produced the Medicare Supplement Annual Directory

PERSONAL INJURY ATTORNEY

Rudolph and Rudolph

Scottsdale, AZ

Performed intake evaluation of potential cases and clients

Handled personal case load through trial

Settled claims and negotiated settlement amounts for facilities and providers

SENIOR CLAIMS REPRESENTATIVE

Sentry Insurance, The Hartford

Adjudicated and Settled Property Damage, Bodily Injury Claims and Litigation up to the Policy Limits

MAYOR, CITY OF DELAFIELD

MEDICAL LABORATORY TECHNOLOGIST



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