Nancy Waltermire

Nancy’s professional experience includes:

• Performed HIPAA privacy and security reviews to assist health plans and traditional insurance companies enhance their programs proactively as well as with remediation efforts and interactions with the Office of Civil Rights post breach.
• Performed numerous compliance program effectiveness assessments of Medicare Advantage, Part D plans, SNP MOC, and Medicaid Health Plans (MMP, MMAI, & ICP). Implemented numerous First Tier, Downstream, and Related Entity (FDR) oversight programs including pre-contracting assessments and site visits, ongoing auditing and monitoring, and government facing audit protocols.
• Implemented, facilitated, and performed health plan risk adjustment compliance monitoring, oversight and auditing programs. Conducted risk adjustment chart reviews and assist in developing provider education materials. Participate in the planning, development, and standardization of reimbursement processes throughout the enterprise to assure the accurate capture of diagnoses codes. Collaborate with IT, HSD, and CMS/HHS to ensure that data is effectively transmitted to appropriate regulatory agencies and accepted with minimal errors.
• Develop/implement policies and procedures to define and support the programs, as well as tools and technologies for on-going analytics of complete and accurate risk adjustment, and oversee and manage all processes related to data supporting risk adjusted payments including but not limited to the reconciliation of the submission of data to third parties including CMS and vendors, analysis of risk adjustment payments and scores, and implementation and operation of technologies for risk adjustments.
• Assist/implement the reconciliation process under the Health Insurance Exchange, dual eligible management, Medicare Part C & D HCC/Risk Score Coding and Accuracy, Medicare Part D PDE management and reconciliation. Develop tools to educate/inform all management including senior officers and board members on changes in the marketplace as well as state and federal regulatory changes related to risk adjustment, reinsurance, and revenue management. Manage vendor agreements and relationships. Assist with the negotiating, contracting, and managing of vendors. These included home assessment vendors, data submission vendors, special clinic vendors, coding and data analyst vendors, software companies, or other subject matter experts/consultants.
• Facilitate/oversee both internal and external audits associated with risk adjustment/reimbursement including RADV from CMS.
• Performed in-depth process and system reviews as well as transaction testing of coverage and organizational determinations, appeals and grievances departments across numerous health plans, and PBMs’ systems and vendors. Issues included: Medicare Part B versus Part D determinations, provider outreach, proper notification, medical necessity, and documentation. Results included developing ongoing auditing and monitoring dashboards for key performance indicators as well as process re-design. Conduct due diligence pre-delegation reviews of vendors performing.
• Performed regulatory compliance diligence related to several potential transactions occurring between entities involved with the Medicare Advantage program related to their risk adjustment programs.
• Developed and implemented utilization management and case management programs in accordance with CMS Special Needs Plans Model of Care requirements.
• Performed an audit of a newly implemented D-SNP plans utilization management and case management program. This included review of resources, policies and procedures, and clinical decision-making hierarchy process.
• Designed and implemented Medicare Advantage and Part D (MA-PD) and Prescription Drug Program (PDP) compliance and fraud, waste, and abuse programs.
• Performed CMS approved independent validation audits of health plans part C ODAG, and SNP MOC.
• Served as chief compliance officer and led a team of eight IPA’s and numerous health plans across the United States and Puerto Rico.
• Successfully implemented the CMS Part D Program for a large statewide Blue Cross Blue Shield Plan serving over 300,000 Medicare and Medicaid beneficiaries.