David Reid Sr Director, Operational Performance & Regulatory Support
David Reid is the Senior Director of Operational Performance & Regulatory Support at Florida Blue with over 16 years of experience in the insurance industry. A Certified Information Systems Auditor (CISA), he is accountable for ensuring business processes across multiple divisions are operationally effective and adhere to regulatory and industry requirements. David’s background is in systems development, database administration, internal auditing, process improvement, operations management and regulatory/accreditation compliance.
Angela Lloyd Dir. Medicare Audit & Corrective Action
Health Partners Plans
Angela Lloyd, MPH is the director of Medicare audit and corrective action at Health Partners Plans of Philadelphia (HPP). Angela is responsible for the oversight of Medicare audit program, which includes operations and processes, analyzing data, reviewing Policies and Procedures, documenting work and drafting audit reports. She also works collaboratively with leadership of operational units, and partners with vendors to ensure corrective action plans are developed and manages them through implementation.
Angela has worked at HPP for 13 years and has over twenty years of product, compliance and operations experience in Medicaid and Medicare programs. Angela’s creative and result focused program has proven successful in driving compliance throughout the organization. Her expertise in the execution of regulatory contractual requirements with the understanding of policy in various channels has improved the companies understanding and awareness of the products offered under the Centers of Medicare and Medicaid Services especially the Special Needs product. Angela truly strives for excellence in everything she does keeping the HPP communities and membership in mind. Angela received a bachelor’s degree in business law, graduate degree in public health from Drexel University and is certified in HealthCare Compliance.
Michelle Fogg serves as Manager of Operational Compliance for Health Partners Plans. In this role, she is responsible for leading and overseeing the internal and external monitoring processes under the Medicare line of business; ensuring compliance with state and federal laws and regulations. Her direct oversight spans from Pharmacy, Transition Letters, Member Relations, Enrollment, Sales (internal and external), Organization Determination, Coverage Determinations, Appeals (C & D), Grievances (C & D), Claims, LEP, LIS, Network Management, and SNP MOC. She is also responsible for creating and implementing Health Partners Plans’ FDR Program.
Michelle has over 17 years’ experience working within the insurance industry, with 13 years working directly under the Medicare umbrella in local Philadelphia plans as well as national plans. Michelle’s initial introduction to insurance started out in the call center where she developed a strong sense of wanting to educate the members on their health benefits. It was not until she began working with the Medicare business that she truly fell in love with compliance. This resolve stuck with her through her many positions that she has held under Medicare that includes creating a platform in a national organization to review the impact of complaints, process improvement efforts, and conducting monitoring efforts to ensure operational compliance to proactively foresee negative impacts to name a few.
Denise Stasik Vice President Credentialing and Advocacy
MVP Health Care
Denise Stasik has many years of experience in the world of healthcare, including clinical, regulatory affairs, and health plan roles. She currently serves as the Vice President of Credentialing and Appeals at MVP Health Care in Schenectady, New York. Denise worked for several years as a consultant and clinical auditor for the New York State Department of Health. She serves on the Board of Directors of AIM Services, Inc., a not for profit organization dedicated to supporting the “power of potential” in people of diverse abilities. She is also very active in other community nonprofits, providing direct assistance to those with medical needs and those under hospice care. For the last 12 years, Denise has traveled to Africa many times, and more recently, to Haiti, leading educational and healthcare projects in rural communities.
Heather Metz is a Manager of Government Compliance for Gateway Health Plan, headquartered in Pittsburgh, PA.In this role, she is responsible for leading organization initiatives for preventing, detecting and correcting issues of non-compliance and mitigating member access to care issues.
An experienced industry professional at both the provider and plan level, Heather joined Gateway Health Plan in 2011 as the organization’s Appeals and Grievances Compliance Analyst before joining the organization’s Corporate Compliance Team in 2016.Heather assumed the role of Manager of Government Compliance in 2017 and has since played an integral role in developing the organization’s compliance program.Heather has lead the development and implementation of Gateway’s internal and external compliance audit program, which includes comprehensive risk assessment, auditing protocols, root cause analysis and corrective action processes.
Heather is certified in healthcare compliance (CHC) with Health Care Compliance Association (HCCA).She received a B.S. in Social Work from Frostburg State University and holds a M.S. degree in Law and Public Policy from California University of Pennsylvania.Heather resides in Pittsburgh, PA with her husband and two dogs.
Sherry Goble is the Clinical Accreditation & Regulatory Consultant at Florida Blue. In this role, she is responsible for ensuring delegated entities that perform the UM prior authorizations are reviewing requests accurately using CMS’ hierarchy for decision-making and decision letters are written in a manner that is compliant with CMS requirements. Over the years, she has worked with the delegates and created best practices that they share with other plans.
Sherry has over 20 years of experience in the insurance industry with a background in Commercial and Medicare Member Appeals, Quality and Risk Management. She is a Registered Nurse in the state of Florida.
Deborah joined SummaCare as the Medicare Compliance Officer in January 2015, and became the Chief Compliance Officer for the insurance arm of Summa Health (SummaCare and Summa Insurance Company) later that year. She is responsible for the health plan compliance program, encompassing all lines of business with an emphasis on Medicare Advantage, Part D, and Marketplace products. Deborah became the health plan Privacy Officer in 2017.
Prior to joining SummaCare, Deborah served as the Compliance & Privacy Officer for Health Alliance Plan in Detroit, Michigan for 12 years. She was in-house counsel, focusing on regulatory compliance, for Univera Healthcare in Buffalo, NY from 1996 to July 2002.
Deborah earned a law degree from Case Western Reserve University in Cleveland Ohio in 1995 and is licensed to practice in Ohio (inactive status), New York (retired status), and Michigan (active status). She received her certification in healthcare compliance (CHC) in 2009.
Caroline Spencer STARS Program Manager/A&G Manager
Memorial Hermann Health Plan
Caroline Spencer is the Manager of the STARS Program and the Appeals & Grievances department for Memorial Hermann Health Plan. She has worked in the managed care industry for 20 years. Her work experience spans from Regulatory Compliance to Operational Management. She joined Memorial Hermann Health Plan in 2016 initially as the STARS Program Manager, and then her management responsibility evolved to include the Appeals & Grievance team. She believes that the Appeals & Grievances department is key to identifying opportunities for improving the members’ experience and satisfaction with the plan, which are important factors to the Star ratings. Prior to joining Memorial Hermann, Caroline served as a consultant with Optum in the Risk, Quality, and Network Solutions division by implementing quality initiatives to improve HEDIS/Stars and Risk Adjustment programs.
Lydia Wardi is a licensed clinical social worker in the state of Pennsylvania and a 2020 Juris Doctor Candidate at Duquesne University School of Law. Prior to joining Gateway Health in 2016, Lydia served as a clinical social worker in an inpatient psychiatric hospital on a geriatric unit. As a member of a multidisciplinary team, she treated patients with acute psychiatric and medical comorbidities, and facilitated community integration.
Lydia was initially hired at Gateway Health because of her clinical expertise. She currently supports the Utilization Management Department and serves as Medicare Compliance Special Needs Plan Model of Care (SNP MOC) subject matter expert. In November 2018, Lydia assumed the position of Senior Regulatory Analyst, where she responsible for spearheading regulatory initiatives like the recently effectuated CMS Preclusion List, the annual Readiness Checklist, and Call Letter. Also attendant to her responsibilities is ingesting, analyzing, and operationalizing approximately 500 HPMS memoranda annually.
Babette S. Edgar, Pharm.D., MBA, FAMCP is a Principal at BluePeak Advisors (BPA). Babette has been in the managed care industry for over 25 years and advises health plans, pharmacy benefit management companies and pharmaceutical companies on Medicare and managed care strategies, operational and compliance issues. Throughout her tenure, Babette has conducted and supported numerous audits with her primary expertise in Part D Coverage Determinations, Appeals and Grievances (CDAG). Prior to starting her own firm, Babette worked at CatalystRx, where she was President, Government Services and ran the Medicare business for the fourth largest PBM. Babette was the Director of the Division of Finance and Operations for the Medicare Drug Benefit Group at the Centers for Medicare and Medicaid (CMS), where she directed building and implementing the formulary and benefit design review processes for the Part D drug benefit. She oversaw the CMS Part D team that developed the agency’s marketing guidelines and marketing models, and conducted oversight of the marketing review process. Babette also directed CMS operations for reviewing and monitoring the licensure and solvency of Part D plan sponsors, assisted in developing transition guidance for Part D plans with patients migrating from Medicaid or other benefits; and provided input into the Part D regulations and other subregulatory guidance from a managed care pharmacy perspective. Previous to her term at CMS, Babette was Vice President, Clinical Business Development at Caremark/AdvancePCS, where she directed sales, account management and product development for a multi-million-dollar disease management product line. She oversaw 16 premier accounts, including Blue Cross plans, managed health plans, Medicare/Medicaid, third party administrators and large and small employers. Babette previously served as Director of Clinical Services for Advance Paradigm, where she ran the P and T process, developed physician and patient education materials, performed academic detailing, and managed the clinical team responsible for developing clinical content and clinical strategy. She also performed business development for specialty services in the Theracom division. Babette has authored many articles in peer-reviewed journals, and has been a speaker at many national meetings, conferences and symposia. She is the Immediate Past President of the Academy of Managed Care Pharmacy and is a national thought leader in topics related to managed care pharmacy, Medicare strategy and value-based pharmaceutical care.
Diane R. Ramey, RPh, CHC is a Senior Director at Ankura based in Phoenix. She has been in the healthcare industry for over 30 years and has been involved in Medicare Part D since its inception in 2006. Diane has successfully launched comprehensive Part D compliance programs, meeting all CMS requirements and has served as corporate/Medicare compliance officer for multiple PBMs.
Mariah Emerich currently leads the Government Programs Appeals & Grievances team at Moda Health in Portland, OR. She graduated summa cum laude from Concordia University Portland in 2008 with a BA in psychology. She has worked in the healthcare field for 10 years and spent the last 7 with Moda Health. She is responsible for the operations of the organization’s Medicaid and Medicare member and non-contract provider appeals, grievances, independent reviews, administrative law judge hearings, CTMs and payment disputes. She feels her biggest accomplishments are increasing the appeal and CTM Star Rating measures and her work to improve customer service compliance with reporting appeals and grievances through the implementation of new training and auditing programs. When she is not lecturing customer service representatives or analyzing appeals data she spends time playing with her bulldog, going on lunchtime runs and enjoying Portland’s many amazing restaurants.
Jon Swisher is the Director of Solution Development for Kiriworks, a leading provider of information and process management solutions that optimize and transform today's business. He has worked as a trusted advisor with both healthcare providers and insurers for close to a decade – utilizing software solutions to drive innovation and process improvement. This includes designing enterprise-class case management platforms, integrating with industry leading EMRs and developing technology roadmaps for the interconnected healthcare ecosystem.
Hayley Ellington-Buckles joined Versant Health, through Davis Vision, in 2012. She is responsible for overseeing regulatory, compliance, and ethics matters across Davis Vision and Superior Vision. She has more than 20 years of managed care, legal, compliance, and operations experience working for insurance and specialty health organizations. Her multidisciplinary experience gives her a unique perspective on influencing the successful integration of compliance across every area of the organization.
Prior to joining Versant Health, Hayley served as legal counsel for Humana Inc. During her tenure with Humana, she was counsel to Humana’s second largest market and focused on various subject areas including regulatory compliance, PPACA, behavioral health, and special investigations among others.
Hayley is a graduate of the University of Texas, Arlington with a Bachelor of Arts in Interdisciplinary Studies-Corporate Compliance and a Juris Doctor from Texas A&M School of Law (formerly Texas Wesleyan).
JoAnn has more than 10 years of experience in healthcare and human services. Prior to joining Community Care Plan, JoAnn served as Corporate Compliance and Privacy Administrator for MDLIVE, as well as Corporate Compliance Manager for MDLIVE, based in Sunrise, FL, and Corporate Compliance Analyst for Gateway Health Plan, in Pittsburgh, PA. JoAnn received her Master of Science in Criminal Justice Administration and her Bachelor of Science in Criminal Justice from Point Park University. JoAnn is a member of the Healthcare Compliance Association. She has demonstrated her commitment as a volunteer for South Florida Cares Mentoring Movement for Broward Public Schools.
Michelle D. Rigby, CFE, CHC is a Director at BluePeak Advisors (BPA).Michelle has 20 years of health care compliance experience at both the health plan and Pharmacy Benefit Manager, (PBM) level to include Medicare, Medicaid and Commercial products. She possesses extensive knowledge in the areas of insurance investigations, government audits, PBM services, Medicare A, B, C and D, Medicaid and Commercial Health Plans. She has recently been an Interim Compliance Officer at an MA Plan and supported them through a CMS Program Audit. The focus of her position is to assist clients with their needs in compliance, audits and Fraud, Waste and Abuse, (FWA) as well as interpretation and adherence to governmental regulations.
She has been involved in Medicare Part D since its inception in 2006, helping to launch a plan comprised of seven Blue Cross Plans as well as building the compliance program at a large PBM. Michelle has been the lead auditor on 20 CMS Program audits her expertise is in CPE, CDAG and FA.She has completed over 200 CMS audits to date. Her collaboration with operational leads for quality improvement initiatives led to numerous successful audits. Michelle developed a successful, proactive CMS Mock Audit program, to jointly assist the Plan and PBM in being fully prepared and to foster teamwork and collaboration. Her experience in building FWA programs at the Plan and PBM level has been instrumental to clients looking to add or grow this functionality within their program.
Recently, Michelle managed the Internal & External Audit and corporate Fraud Waste and Abuse programs while helping with Medicare Compliance support for numerous large clients. Michelle is a Certified Fraud Examiner and Certified in Health Compliance and has spoken extensively on FWA and Compliance topics throughout the United States.
Nancy Waltermire is a Senior Director at Ankura. Nancy is a seasoned professional with proven ability to manage multi-functional areas of operations and maintain compliance with federal and state regulations. Successful in the implementation and administration of government contracts. Nancy provides consulting and expert services relating to regulatory compliance and operations in the commercial and government-sponsored programs space. Her experience includes working with payers (commercial, Medicare Advantage and Part D, SNP MOC, Medicaid, and Affordable Care Act) providers (ancillary providers and pharmacies), and pharmaceutical manufacturers.
Melissa Rusk is the Director Claims and BPO Operations at SummaCare in Akron Ohio. In this role, Melissa is responsible for leading Claims, Claims Recovery, and Document Management Services. She leads and oversees multiple internal efforts to ensure compliance with federal and state regulatory requirements and plan performance guarantees. This includes: Fraud Waste and Abuse, FDR management, payment integrity, implementation of new plans and plan changes, weekly and monthly performance monitoring, system upgrades and new system implementation, encounter submissions, and plan audits. She oversees business decisions associated with coverage and payment policies.
Melissa has over 30 years’ experience working within the insurance industry in customer service, compliance and operations.
She is a Lean Six Sigma Green Belt and is certified in Lean by the University of Akron.
Delores Stewart (MAcc) is a Senior Manager within Operational Performance & Regulatory Support at Florida Blue. She is accountable for the CMS Mock Audit Program and vendor oversight activities. An experienced Senior Auditor from Deloitte & Touche, Delores is a licensed CPA, former Finance Manager at UF Health (First Coast Advantage, LLC) and worked for Florida’s Office of the Attorney General as a Medicaid Fraud Auditor prior to joining Florida Blue.
Director of Appeals, Grievance, and Customer Solutions MHK
Jason Kaylor Director of Appeals, Grievance, and Customer Solutions MHK
As Director of Appeals, Grievance, and Customer Solutions, Jason Kaylor leads product development and continual innovation of compliant and efficient Appeals and Grievance components of the MedHOK platform. Jason also provides leadership and direction to a product development and client support team responsible for client implementations and ongoing platform support throughout the client partnership. The product development and support team ensures that the MedHOK platform components and functionality provided to each client serve their business-specific needs, maximize efficiency, and maintain continual compliance with all Medicare, Medicaid, Commercial, and Exchange regulations.
Jason brings 15 years of health plan and information technology experience to his role at MedHOK. Prior to joining MedHOK, Jason served as Manager of Injectable Medications at WellCare for five years and Pharmacy Supervisor at Walgreens for six years.
Debbie Hill Senior Director, UM Product Applications
Debbie Hill is a master’s prepared registered nurse with over 30 years’ experience in healthcare. She is the senior director for utilization management and appeals & grievances product applications at Medecision, a leading population management technology organization. Her role as a clinical consultant to the platform engineering team includes research, product development, and application deployment for healthcare payers serving Medicare, Medicaid, and commercial lines of business. As a clinician dedicated to service excellence, Debbie and her team consistently review and update products and reporting tools to ensure all current regulatory needs are accurately captured.
Prior to her role at Medecision, Debbie gained her technical experience some 15 years ago as a clinical consultant for ZeOmega and Altruista Health, and then as a clinical informaticist within the University of Pittsburgh Medical Center (UPMC) Health Plan’s internal proprietary software operation.
Debbie has worked extensively within both payer and workers’ compensation operations as a case and utilization management nurse, manager, director, and associate vice president of onsite case management. While supervising some 50 on premise and remote clinicians, Debbie honed her skills at managing communication, building teams, and breaking down internal silos.
Debbie is a graduate of the Washington Hospital School of Nursing and the University of Arizona, and forged her early clinical career in the emergency department and the cardiovascular ICU before her foray into the case and utilization management arena. She is a resident of Pittsburgh, PA and her daughter is a college freshman. As a new empty nester, she enjoys watching and attending Pittsburgh sporting events and spending time with her Yorkie and two cats.
Nannette “Nan” Sloan is an experienced healthcare executive with 20+ years of experience in healthcare regulatory and compliance; creating and delivering EHR, Laboratory, Process Optimization, and Payer Case Management solutions for clients; and leading strategy and business development. In her role as Senior Director of Compliance at Medecision, she sets the direction for regulatory and compliance, operations, and program management teams to maximize the customer experience. Nan has experience implementing solutions to track regulatory requirements, certifying products in alignment with regulatory requirements, delivering regulatory and compliance internal education certification plans, implementing corporate compliance plan, managing high-level client relationships, and driving corporate transformation.