Lina Darsa
Hialeah,USA
Summary
Talented and professional individual with a deep understanding of industry practices. Brings six years of valuable expertise to drive forward company objectives. Known for dedication and problem-solving abilities, considered a knowledgeable leader in the field. Has successfully coordinated various projects, programs, and improvements with a keen eye for detail, ensuring seamless execution.
Overview
18
18
years of professional experience
Work History
Florida D-SNP Business Project Manager
Aetna Health Inc.
04.2019 - Current
- Responsible for facilitating and driving the strategic development of Individual Medicare Advantage Dual Eligible Special Needs (D-SNP) plans
- Accountable for Individual Medicare Advantage DSNP product development and strategy
- Responsible for research and review large amounts of competitive, market and benefit datasets and use information to drive and develop strategy
- Responsible for managing Florida Medicaid Contract and ensuring plan compliance
Medicare Compliance Consultant
Self Employed
03.2015 - 04.2019
- Served as subject matter expert for the operational functions of Medicare products within an assigned market
- Assisted with the execution of all CMS required activities and processes including the accuracy and compliance of the annual bid application, expansion application, member materials, and group setup
- Supported internal and external Medicare audit activity including CMS and operation integrity audits
- Coordinated file pulls, data requests, universe development, and supporting documentation
- Maintained an awareness of trends, developments, and governmental regulations in Medicare and managed health care organizations
- Provided consultative support for Medicare product design features, integration schedule, and operational readiness in a new product start-up environment
- Supported member retention activities, including development of outreach materials, design/implementation of outreach programs both directly and in coordination with corporate member retention team, development of talking points/ educational pieces about market specific issues
- Monitored sales and marketing activities to assure adherence to Federal and State regulations
Medicare Marketing Consultant
Lance Soft for Aetna Better Health
01.2018 - 09.2018
- Ensured timely implementation of regulatory requirements
- Conducted oversight by auditing, monitoring, and evaluating compliance risks
- Interfaced with regulators on compliance matters and ensure documentation to demonstrate an effective Medicare Compliance program
Director of Compliance
Florida Healthcare Plus, Inc
10.2011 - 12.2014
- Successfully developed and implemented Compliance, HIPAA, and Anti-Fraud Programs
- Successfully developed and implemented a regulatory compliance program that met the expectations of State and Federal regulators and corporate Government Programs
- Collaborated with Human Resources and developed a Code of Conduct that outlined and provided employees with expectations of behavioral and the ability to report compliance and anti-fraud related issues
- Monitored the performance of the health plan compliance and anti-fraud programs on an ongoing basis, taking appropriate steps to improve its effectiveness
- Coordinated investigations with legal counsel for violations of law or policy, and as a part of the anti-fraud program
- Assisted the compliance committee to effectively incorporate the compliance and anti-fraud programs
- Conducted ongoing identification and annual evaluation for potential areas of non-compliance, privacy and security risk, and fraud, waste and abuse detection and investigation, and reporting
- Coordinated resources to ensure the ongoing effectiveness of the compliance program
- Successfully ensured the development of Compliance, HIPAA, and Fraud Waste and Abuse training programs
- Oversaw a full range of waste, abuse and fraud investigations, audits and track and trending of marketing allegations
- Successfully ensured all audits adhere to federal and state Medicaid and Medicare fraud, waste, and abuse guidelines
- Oversaw the activities of the SIU for accurate and timely operational reviews and final reviews Interpret audit results and assist health plan executives in the development of appropriate action plans to address identified risks
- Successfully developed and implemented continuous auditing processes from analytic design to final report stage
- Identified and direct the implementation of new technologies
- Created a successful marketing campaign for the Medicare open enrollment period
Government Contracting Specialist
Molina Healthcare of Florida
12.2008 - 09.2011
- Assisted Director in role of primary contact with government agencies regarding plan issues and requirements and coordinate with other departments in resolution process
- Review of materials for compliance and approval of AHCA guidelines
- Perform initial contract review, preparation, identification of reporting requirements and filing of reports
- Review of policies and procedures
- Participation in department and government agency meetings as required
- Successfully ensured that the day-to-day regulatory needs of the Medicaid product line were being met, including inquiry resolution, Agency for Healthcare Administration (AHCA) interface, and company-wide regulatory resource
- Directed multiple regulatory projects with aggressive deadlines and met deadlines 100% of the time
- Provided cross-departmental support to the Medicaid product line, working closely with Member Services, Health Services, Finance and Provider Relations, and through such ongoing activities as material review and development, policy and procedure development and maintenance, leading regulatory meetings, and training
- Successfully developed and enhanced relationships with Agency for Healthcare Administration (AHCA) and other government entities through relationship building, regulatory analysis, and representation at meetings, conferences, other events, legislative/regulatory tracking, and analysis
- Developed cross-departmental processes; build interdepartmental relationships, and team building
Compliance Specialist
Care Plus Health Plans
08.2006 - 12.2008
- Successfully managed the regulatory needs of the Medicare Product Line by coordinating the day-to-day relationship with CMS, including, but not limited to, material development, submission and approvals, inquiry resolution, communication coordination and dissemination, compliance monitoring and auditing, policy and procedure development and maintenance, audit preparation, regulatory analysis, regulatory synopsis and dissemination, and government relations
- Successfully ensured that the day-to-day regulatory needs of the Medicare product line were being met, including inquiry resolution, CMS Regional Office interface, and company-wide regulatory resource
- Directed multiple regulatory projects with aggressive deadlines and met deadlines 100 % of the time
- Provided cross-departmental support to the Medicare product line, working closely with Sales, Marketing, Member Services, Health Services, Finance and Provider Relations, and through such ongoing activities as material review and development, compliance monitoring and auditing, policy and procedure development and maintenance, leading regulatory meetings, training
- Successfully developed and enhances relationships with CMS and other government entities through relationship building, regulatory analysis, and representation at meetings, conferences, other events, legislative/regulatory tracking and analysis, white paper development on key regulatory topics
Education
MBA - Business Administration
Florida International University
Miami, FL08.2016
Bachelor of Science - Criminal Justice/Policy Administration
Florida International University
Miami, FL08.2008
Skills
- Multi-unit operations management
- Workflow planning
- Performance improvements
- Systems implementation
- Processes and procedures
- Microsoft Office Suite expert
Languages
Spanish
Native or Bilingual
Timeline
Florida D-SNP Business Project Manager
Aetna Health Inc.
04.2019 - Current
Medicare Marketing Consultant
Lance Soft for Aetna Better Health
01.2018 - 09.2018
Medicare Compliance Consultant
Self Employed
03.2015 - 04.2019
Director of Compliance
Florida Healthcare Plus, Inc
10.2011 - 12.2014
Government Contracting Specialist
Molina Healthcare of Florida
12.2008 - 09.2011
Compliance Specialist
Care Plus Health Plans
08.2006 - 12.2008
Bachelor of Science - Criminal Justice/Policy Administration
Florida International University
MBA - Business Administration
Florida International University
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