Stephanie Rivera Pabón

• Evaluate providers proposals and negotiate fees
• Manage special or custom negotiations with providers for Commercial, Medicaid and Medicare Advantage Lines of Business.
• Negotiate favorable pricing structures with Providers and enhance profitability.
• Improved Providers relationships through timely and accurate contract administration.
• Analyze and implementing required changes to proactively comply with new regulations.

• Report directly to the Vice President of Regulatory Affairs
• Supervise staff performance, provide training and technical support based on state and federal regulations
• Analyze policy changes at state and federal level, validate impact on the organization and implement necessary changes
• Principal liaison between Subcontractors and the Managed Care Organization for the delivery of services contracted
• Principal liaison between Government officials and the Managed Care Organization
• Develop audit work plan, focused on the oversight of Subcontractors and the Managed Care Organization to assure quality of services
• Prepare and present comprehensive administrative reports to upper management and audit team, covering issues and recommendations
• Initiate, monitor and/or support corrective actions and continuous improvement plans identified through the analysis of performance indicators based on regulatory requirements and contractual requirements
• Coordinate and lead the Delegation Oversight Committee in which administrative, quality and compliance initiatives are discussed
• Evaluate contracting subcontractors, by assessing capacity to provide required services and develop recommendations based on the results of the evaluation
• Manage, coordinate and oversee compliance with regulatory agencies requests, including managing ad hoc requests with a deadline to respond within 24 hour or less
• Maintain reporting requirements calendar to ensure timely review and submission of regulatory reports
• Validate and identify gaps in regulatory reports requested by state and federal agencies
• Oversee implementation of new reporting requirements and coordinate meetings with executive leaders to ensure understanding and compliance with requirements

• Assisted Medicare Compliance Director in the review, implementation and maintenance of the Compliance Program to ensure its effectiveness
• Assisted in the development, maintenance and review of policies and procedures for the general operation of the Compliance Program and its related activities, according to state and federal regulations
• Liaison between First Plus (Medicare Advantage line of business) and other government agencies
• Assisted in the organization of the Compliance Committee, including development of agendas, reports and information requested by the Compliance Committee, the President and / or Board of Directors
• Identified potential areas of vulnerability and compliance risk within the line of Medicare / Medicaid businesses; developed and implemented corrective action plans for resolution of problematic issues and provided general guidance on how to avoid or deal with similar situations in the future
• Assisted the Human Resources Department in the continuous training for all Employees, Managers and Directors
• Assisted other departments in understanding regulatory requirements
• Provided oversight of the submission of regulatory reports and activities
• Coordinated and monitored compliance activities with other departments and resources, as needed
• Performed follow up activities for all matters relating to the Compliance department, including corrective actions resolution
• Kept track of regulations and notifications distributed by CMS (HPMS notices) and other government agencies to identify potential impacts on the operations of the Company
• Responsible of interpretation of federal and state policy changes and impact on the organization
• Encouraged managers and employees to report suspected fraud and other irregularities without fear of retaliation
• Lead CMS conference calls with designated CMS Account Manager
• Prepared reports as requested by CMS Account manager
• Assisted in the preparation of materials for CMS audits
• Assisted in regulatory audits and visits
• Coordinated internal audits and delegated entities audits to ensure compliance
• Prepared internal and delegated entities audit reports to be presented to Board of Directors

• Developed, initiated, maintained and reviewed policies and procedures for the general operation of the organization compliance program and its related activities to prevent illegal, unethical or improper conduct
• Collaborated with other departments (e.g
• Risk Management, Internal Audit, Employee Services) to direct compliance issues to appropriate existing channels for investigation and resolution
• Monitored and coordinated compliance activities of other departments to remain abreast of the status of all compliance activities and to identify trends
• Identified potential areas of compliance vulnerability and risk; develop/implement corrective action plans for resolution of problematic issues and provide general guidance on how to avoid similar situations in the future
• Provided reports on a regular basis, and as requested kept the senior management informed of the operation and progress of compliance efforts
• Maintained an effective compliance program for the organization, including promoting heightened awareness of Standards of Conduct, clear understanding of new and existing compliance issues and related policies and procedures
• Monitored the performance of the Compliance Program and related activities on a continuing basis
• Developed and submitted products to the Office of Insurance Commissioner, regulatory agencies and programs