Adriana Phillips
Palmetto Bay
Summary
Dynamic compliance leader with extensive experience in Managed Care, specializing in Medicare compliance and federal regulations. Proven track record in driving quality assurance initiatives and fostering a culture of ethical behavior. Bilingual in English and Spanish, adept at clear communication and motivated to achieve operational excellence.
Strong focus on team collaboration and achieving results. Reliable and adaptable with changing needs.
Overview
22
22
years of professional experience
Work History
Staff Vice-President GB Compliance
Sales, Marketing & Regulator Audit Elevance Health
02.2023 - Current
- Ensure compliance with all relevant federal and state laws and regulations governing Sales and Marketing activities.
- Conduct oversight of all marketing collateral and mandated marketing materials as required by the Centers for Medicare and Medicaid Services (CMS) and State Agencies.
- Identify, assess, and mitigate potential risks associated with managed care sales and marketing activities.
- Provide consistent and on-going support to the sales and marketing teams, providing training, coaching and performance management.
- Lead a team of 20 plus members, supported the professional development of team members by regularly sharing best practices, encouraging ongoing learning, and promoting a culture of continuous improvement.
- Analyzed performance data to identify trends and areas for improvement.
- Conduct market research and analysis to identify opportunities and target markets for managed care products and services.
- Led the Government Business external audit teams in the performance of external audit activities by overseeing and managing the audit processes pertaining to Medicare and Medicaid Audits, ensuring accuracy, identifying potential issues, tracking, reporting and implementing corrective actions while maintaining compliance with Federal and State Regulations.
- managed relationships with external auditors and consulting groups to mitigate regulatory issues and help ensure compliance with federal and state requirements.
- Lead the annual forecast and planning of audit activities, budget and resources.
- Provided strategic guidance to help senior leadership identify and implement appropriate corrective action plans.
- Established positive relationships with business partners and internal and external staff members.
Strategic Compliance Business Leader -MMM PR
Anthem, Inc.
06.2021 - 02.2023
- Assist and support the MMM Team in navigating the Anthem organization.
- Collaborate with MMM Compliance and cross-functional teams to identify best practices and Compliance alignment opportunities.
- Oversee the compliance aspect of integration, ensuring compliance requirements were adhered to.
- Built strong relationships with MMM associates through positive attitude and attentive response.
- Prepare and present regular reports on compliance activities and issues to senior management.
- Promote a culture of ethical behavior and compliance within the organization.
Compliance Director II, HealthSun
Anthem, Inc.
01.2020 - 07.2021
- Dedicated on-site day-to-day business advisory support for HealthSun Health Plans, Delivery Network and EasyScripts Pharmacy.
- Collaborated with operational business areas including Provider relations, Claims, Utilization Management, Customer Service, Information Systems. and Human Resources to direct compliance related processes through existing channels for investigation and resolution.
- Responsible for leading a team of of eight (8) direct reports including directors, managers and senior consultants.
- Reviewed, revised, developed and maintained policies and procedures for the general operation of the compliance program and its related activities to promote adherence to all laws and regulations promoting a culture of compliance.
- Consulted with General Counsel on Compliance matters.
- Developed and lead the HealthSun Compliance Committee and provided on-going reports to senior management of the operation and progress of compliance efforts.
Compliance Director I
Elevance Health, Inc.
03.2017 - 01.2020
- Led Anthem's Compliance First-Tier, Downstream and Related Entity (FDR) Oversight Team which included 400+ FDRs supporting the Medicare, Medicaid and Commercial Lines of Business offered by the organization.
- Maintained the program's effectiveness measure above 95% year over year.
- Lead a high-performance team of ten (10) managers and consultant level associates.
- Implemented policies and procedures to ensure vendors supporting Anthem business met compliance with regulatory and contract requirements.
- partnered with business leaders to ensure appropriate oversight of vendors was conducted.
- Chaired the Compliance FDR Oversight Committee and reported on a quarterly basis to the Anthem Compliance Committee lead by Anthem's Chief Compliance Officer.
- Identified as a high-performance leader and selected to introduce the Florida Strategy Mapping to 1,600 associates across the local market to deliver the organization's strategy, mission, vision and values.
Delegation Oversight Director
Simply Healthcare Plans Inc.
11.2014 - 03.2017
- Led the Simply Healthcare Plans, Inc., Better Health, and Clear Health Alliance Delegation Oversight Program.
- Reviewed vendor contracts, conducted pre-delegation, annual, ad-hoc audits, and on-going monitoring of delegated vendors.
- Conducted oversight of day-to-day vendor operations ensuring required policies and procedures were in place and executed according to regulatory and contract requirements.
- Chair of the Medicaid and Medicare Delegation Oversight Committee, developing and conducting regulatory reporting pertaining to vendor performance.
- Internal and External Audit SME.
- Led a team of four (4) Senior Consultants associates.
Member Services & Grievance and Appeals Director
Simply Healthcare Plans, Inc.
03.2011 - 11.2014
- Oversaw the Plan's call center operations and performance, ensuring efficient customer service and satisfaction while maintaining compliance with regulatory requirements.
- Lead the team of over 30 associates in handling member and provider inquiries, complaints and appeals, ensuring timely and compliant resolutions while improving customer experience and operational efficiency.
- Develop and maintained departmental policies and procedures ensuring compliance with regulatory guidelines and contract requirements for all the lines of business offered by the Plans.
- Established productivity metrics in compliance with call center requirements, developed the staffing model to support the Medicaid Managed Assistance Award granted by the State of Florida to the Plan in 2014.
- Ensured the delivery of excellent customer service to our members and providers while creating the ultimate member experience.
Trainer & Quality Assurance Manager
CarePlus Health Plans | Humana
12.2002 - 03.2011
- Responsible for conducting training training to call center and sales staff.
- Developed teaching aids, service training manuals, on-line documents, visual aids, web tutorials and CMS regulated materials including the Evidence of Coverage, Summary of Benefits, Telephonic Scripts and Handbooks.
- Developed and implemented the organizations corporate training.
- Developed, implemented and maintained the call center quality assurance program ensuring quality levels wcorrective actions were executed.
Education
Mass Communication And Journalism
Universidad De La Sabana
Bogota, ColombiaSkills
- Subject Matter Expert in Medicare Compliance
- Federal and State Regulation
- Healthcare Policy Experience
- Clear Communication Skills
- Bilingual Proficiency: English and Spanish
- Motivated and Detail-Oriented
- Thorough Quality Assurance
- Agile Methodologies
- Quality Controls
Timeline
Staff Vice-President GB Compliance
Sales, Marketing & Regulator Audit Elevance Health
02.2023 - Current
Strategic Compliance Business Leader -MMM PR
Anthem, Inc.
06.2021 - 02.2023
Compliance Director II, HealthSun
Anthem, Inc.
01.2020 - 07.2021
Compliance Director I
Elevance Health, Inc.
03.2017 - 01.2020
Delegation Oversight Director
Simply Healthcare Plans Inc.
11.2014 - 03.2017
Member Services & Grievance and Appeals Director
Simply Healthcare Plans, Inc.
03.2011 - 11.2014
Trainer & Quality Assurance Manager
CarePlus Health Plans | Humana
12.2002 - 03.2011
Mass Communication And Journalism
Universidad De La Sabana
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