Carmen Winters is a Senior Health Plan Services Consultant with BluePeak Advisors, a division of Gallagher Benefit Services, Inc. Carmen is an experienced compliance officer and consultant with nearly 25 years of Federal and State Compliance Program development and management and 30 years of managed care industry experience. Throughout her tenure Carmen has conducted and supported numerous audits with her primary expertise in Compliance Program Effectiveness (CPE), Organization Determinations, Appeals and Grievances (ODAG), and Coverage Determinations, Appeals and Grievances (CDAG). Carmen also provides support for call centers, enrollment departments and oversight of sales and marketing activities.
As a consultant, Carmen has taken leadership positions with clients assisting them with both operations and compliance. She served as Interim Vice President of Operations for a start-up Medicare Advantage Prescription Drug (MAPD) plan offering chronic and dual Special Needs Plans (SNP). Carmen spent over a year serving as Interim Chief Compliance Officer for multi-state organization offering Prescription Drug Plan (PDP), MAPD and SNP products. She has served as the project lead addressing end-to-end business processing, delegation and outsourcing oversight and monitoring, development of cross functional policies, procedures and business process development for all types of MA Plans (CCP, POS, PFFS, EGWP, SNP and fully integrated dual/Medicare-Medicaid plans (FIDA/MMP) and stand-alone PDPs. Carmen also assists with plan benefit package development and marketing material development and compliance review. She specializes in leading projects for clients including audit preparation and remediation, operational and compliance risk assessments, delegation oversight, as well as the identification and implementation of corrective action plans. She supports plan sponsors with organizational development, state and federal applications, enrollment, customer service, sales oversight, coverage and organization determinations, appeals and grievance management as well as regulatory compliance and oversight, auditing and monitoring. She works with organizations on the full spectrum of applications to CMS for new Part C, Part D, SNP applications, service area expansion applications, and when necessary, operationalizing and implementing service area reductions.
Prior to becoming a consultant, she served in various roles for local and national MAPD in the areas of member services, marketing, appeals and grievances, enrollment, individual programs operations, provider network management and compliance.