Scottsdale, AZ 85260
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.
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.
J.D., DePaul University, College of Law, Chicago, IL
B.A., Political Science, University of Wisconsin-Milwaukee
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)
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
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
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
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