Rise

Tami Ben-Dor Sr. Manager, Client Audit 

CVS Health

Tami has been with CVS Health for 18 years.  She started her pharmacy benefit management (PBM) career in Internal Audit and transitioned to Client Audit, where she has held multiple leadership roles involving various audit types and lines of business.  In her current role, Ms. Ben-Dor supports Medicare Part D CMS Program, Validation and client- initiated mock audits. Her area of expertise is Coverage Determinations, Appeals and Grievances (CDAG).  As the CDAG audit lead for CMS Program Audits, Ms. Ben-Dor is responsible for managing all aspects of the CDAG portion of the audit to ensure a smooth and successful experience for all parties involved, both internally and externally. This responsibility spans the entire audit life cycle, from pre-audit preparation to live audit support and post-audit activities.  Activities include universe creation, risk assessment, coordinating CVS SME support, traveling to the client’s offices for onsite audit support, sample research and overseeing deliverables. A recent accomplishment for Ms. Ben-Dor is having served as the CDAG audit lead for a fully-delegated Health Plan client that received a perfect overall audit score. 

Ms. Ben-Dor takes a consultative approach in working alongside her clients, which include internal business partners as well as Health Plans. Her strengths lie in her leadership and exceptional analytical skills, which help her to successfully drive internal process improvements across the CVS Health book of business and collaborate with and influence clients to positive audit outcomes.

Ms. Ben-Dor earned her Bachelor of Science degree in Accounting from Arizona State University and is a Certified Public Accountant.

Christopher Bresette, CPA Director, Medicare Part C Audits

HHS Office of Inspector General

Wynda Clayton Risk Adjustment Specialist

Wynda Clayton, MHA, BSHCA, AAS, RHIT, CRC and currently pursuing a DBA in healthcare administration - has over 30 years of experience in the healthcare industry.  Wynda is a risk adjustment specialist with expertise that includes third-party billing, compliance, accounts receivable, and being a RADV auditor, educator, and senior director of risk adjustment for a health plan.  Wynda is a thought leader within the Risk Adjustment community and a frequent speaker at national and regional risk adjustment conferences.

Erin Comer Sr. Manager, Client Audit 

CVS Health

Originally starting with CVS Health in 2014, Erin Comer joined the Client Audit department in 2021.  As a Senior Manager, Mrs. Comer leads health plan clients through the Formulary Administration section of the CMS Program Audit on behalf of CVS Health.  Her responsibilities include: universe creation, risk assessment, coordinating internal and external support, sample research and overseeing multiple deliverables within very tight deadlines.

Mrs. Comer started her PBM career as a Client Benefits Representative analyzing client benefit requests to determine the best operational approach and perform coding to meet client’s intent for their plan benefit setup. She then moved to the Clinical Government Programs team as a lead contributor on the audit and testing team supporting audit and testing activities for the team’s End-Stage Renal Disease (ESRD), Hospice, Transplant, Transition Fill, and Vaccine products. Some of Mrs. Comer’s most outstanding achievements include implementation of comprehensive audit performance reporting, tracking, and analysis. Additionally, she designed and executed comprehensive testing strategies to ensure program effectiveness.

Mrs. Comer earned her Bachelor of Science degree from University of Georgia. She also earned her Master of Public Health degree from A.T. Still University.

Rose T. Dunn Chief Operating Officer

First Class Solutions, Inc.

Ms. Dunn is Chief Operating Officer of St. Louis-based First Class Solutions, Inc.  Rose’s career started at Barnes Hospital, the flagship of BJC Healthcare, where she ultimately was Vice President and responsible for 1,600 employees.

After Barnes, she worked for MetLife as national AVP, where she gained a solid understanding of managed care.  Rose also served as the CFO of an Illinois dual-hospital system and participated in their bond issue. 

Rose is an AHIMA Distinguished Member, Legacy, and Outstanding Service award recipient and has served as the elected President and employed interim CEO of the 80,000-member professional association.  She has served on numerous AHIMA committees, councils, and the Foundation.

She is active in ACHE, AICPA, HFMA, HIMSS, ARMA International, and AHIMA. Rose has authored more than a dozen texts including ACHE/HAP’s Dunn & Haimann’s Healthcare Management, published 200+ articles, and made numerous healthcare related presentations.  She authored and supports the Fundamentals of HCCs course for Libman Education.

In her spare time, she bakes cheesecakes and tends to feral cats.

Joy Enright Lead Director, Client Audit

CVS Health

Joy Enright has been with CVS Health more than 23 years with a current expertise focused on CMS Program audits. Her experience and expertise encompasses operational leadership for several BCBS health plan account management teams as well as successfully leading multiple health plan clients through the CMS Program audit experience. A recent accomplishment is being a leading participant in driving CVS Health’s success when a fully delegated client received a perfect overall audit score for two consecutive audits. This is an industry record marking the first time a plan sponsor was able to achieve a perfect overall audit score, back-to-back, in the Medicare space. Mrs. Enright aims to influence every CVS Health client to attain this same level of success by ensuring that all services delegated to CVS Health receive zero Conditions.

After years of supporting these audits herself, Joy developed a ‘best in class’ audit support structure which included developing a team of high performing leaders who are dedicated to delivering a consultative approach as they work beside internal business partners and CVS Health clients. Joy Enright’s team travels onsite to various client locations across the country to lead and support clients during their CMS Program audits for all services delegated to CVS Health. This support strategy offers real-time, side-by side guidance throughout the audit  experience with a personalized, consultative and proactive approach that has earned her team’s support structure a reputation of being ‘best in class’.

During her tenure, Joy Enright’s team has supported hundreds of CMS program and Compliance Oversight audits. She has a robust ability to lead and execute in a fast paced, constantly changing environment. Mrs. Enright has extensive experience working with health plan clients, consultant firms and CMS auditors to meet and exceed client goals while offering innovative solutions that lead to positive audit outcomes.

Collaborating with clients to mitigate potential audit risk and to deliver outstanding audit results is of the utmost importance to Joy Enright and her goal-focused and success driven leadership team!

Niejadd Evans Director of Corporate Compliance Assurance

MedImpact Healthcare Systems

Niejadd Evans is currently the Director of Corporate Compliance Assurance at MedImpact Healthcare Systems, the nation’s largest privately-owned pharmacy benefit manager
(PBM), offering health and prescription drug insurance plans to self-funded employers and professional organizations. There, he is responsible for all aspects of compliance for the company’s corporate compliance program. For 20+ years, he has held compliance leadership positions at numerous health insurers, payors, and third-party administrators, focusing primarily on government programs compliance (Medicare, Medicaid, Health Insurance Exchange).

Niejadd has a Bachelor of Science degree in Health Care Management from Florida A & M University (FAMU) and a Master of Business Administration degree from Benedictine University. He is also Certified in Healthcare Compliance (CHC) by the Compliance Certification Board.

Colleen Gianatasio Director Clinical Documentation Integrity and Coding Compliance

Capital District Physician’s Health Plan (CDPHP)

Colleen Gianatasio CPC, CPC-P, CPMA, CPC-I, CRC has 18 years of experience in the health insurance field. She has experience in customer service, claims, quality and coding. As Risk Adjustment Quality and Education Program Manager for Capital District Physician’s Health Plan (CDPHP) Colleen’s primary responsibilities are provider engagement and clinical documentation improvement for accurate coding. Colleen specializes in developing innovative coding curriculum and instruction to support compliance with federal guidelines and appropriate reimbursement processes. She is a certified AAPC instructor and enjoys teaching a variety of coding, documentation and auditing classes. Colleen serves as President-Elect of the AAPC National Advisory Board.

Mary Inman Partner

Whistleblower Partners

Mary Inman is a partner in Constantine Cannon’s London and San Francisco Offices. After 20+ years representing whistleblowers in the U.S., she moved to London in July 2017 for four years to launch the firm’s international whistleblower practice and now splits her time between the London and San Francisco offices. She specializes in representing whistleblowers from the U.S., U.K., Europe and worldwide under the American whistleblower reward programs, including the federal and various state False Claims Acts and the SEC, CFTC, IRS, DOT and Treasury Department AML and sanctions whistleblower programs. Ms. Inman’s efforts to export the American whistleblower programs to the United Kingdom, including her efforts on behalf of a successful British whistleblower, were featured in a recent New York Times article “Law Firm Sees Britain as Hunting Ground for U.S. Whistleblower Cases.”  Ms. Inman’s successful representation of three whistleblowers exposing risk adjustment fraud in the Medicare Advantage program was featured in the February 4, 2019 issue of the New Yorker magazine in an article entitled “The Personal Toll of Whistle-Blowing.” Ms. Inman represents renowned SEC whistleblower Tyler Shultz who exposed the now infamous Silicon Valley blood testing start-up Theranos, and regularly speaks on lessons to be learned from this scandal surrounding corporate governance.   

Ava Johnson Associate Director, Ambulatory CDQI

Mount Sinai Hospital, NYC

Ava Johnson is the Associate Director of the Outpatient Clinical Documentation Quality Improvement department at Mount Sinai Hospital in NYC. Ava is a seasoned coding instructor, physician educator, multispecialty coder, CDI specialist and public speaker with a focus on executive leadership and career development.

Carolyn Kapustij Senior Advisor for Managed Care

HHS Office of Inspector General

Carolyn Kapustij serves as a Senior Advisor for Managed Care at the Office of Inspector General (OIG) for the Department of Health and Human Services.  At OIG, she develops and leads enterprise-wide strategies to oversee Medicare Advantage and Medicaid Managed Care programs.  She previously worked at the Centers for Medicare and Medicaid Services (CMS) and oversaw the improper payment measures for Medicare Part C and Part D, developed program integrity activities for the Federally Facilitated Exchanges, and developed payment policy for MA and Medicare Part D plans. She holds a Master of Public Health from the University of Michigan. 

Donna Malone Director Risk Capture, Population Health Management  

Mass General Brigham 

Donna Malone, CPC, CRC, AAPC Approved Instructor, AHCCA, RAP, RISE Fellow: Director Risk Adjustment with Mass General Brigham in MA, Adjunct Professor with MassBay Community College, Chair of the RISE Risk Adjustment Academy HCC Coding Faculty Advisory Group as well as content developer RISE designations and workshops, and 2022-2025 AAPC National Advisory Board. Donna has over 28 years’ experience (Payer, Provider System and Vendor) in healthcare with primary focus on Value-Based Care.

Donna has also served as President of the Watertown AAPC Chapter (2017-2022) and Education officer (2016)

Donna speaks nationally for RISE, AAPC and AHIMA

She also received the 2021 MaHIMA Champion Award

Ken Nuñez Chief Compliance Officer

Provider Partners Management Services

Kenneth (Ken) Nuñez, MBA, CHC is the Chief Compliance Officer for Provider Partners Health Plans. He has held this position since August 2020, and in this role he is the main contact with the Centers for Medicare & Medicaid Services (CMS) for all regulatory, compliance, and audit issues. He has over 29 years combined experience in MA-PD and Large Hospital/Facility Compliance. In his career, he has been involved in dozens of regulatory and OIG Audits including, CMS Program Audits, 1/3 Financial Audits, Data Validation Audits (DVA), Ad-hoc audits, etc.

Here are some notable employment experiences in the MA-PD and Health Care Industry: Worked at United Health Group for seven (7) years as the National Director, Medicare Operational Compliance. Employed at Cigna/HealthSpring for six+ (6+) years as Vice President, Medicare Compliance Audit & Risk Assessment, Worked at WellCare (Centene) for almost four (4) years as the Director, Medicare Regulatory Affairs, and then as the Senior Director, Medicare Compliance Audit.  Employed by Mercy Hospital System (HCA)/Doctor Care Mercy PHO for three (3) years as their Corporate Integrity Officer and then as Vice President, Compliance.

He also served for several years as a senior compliance consultant for boutique national firms assisting Medicare and Medicaid Health Plans in preparation for state and federal audits, compliance re-builds, operational optimization, and post-audit distress.

Laura Sheriff Risk Adjustment Industry Expert

Laura Sheriff, RN, MSN, is currently working as a consultant with physician groups and health plans to capitalize on risk adjustment performance and operations.  Laura is an MSN with >12 years’ experience in Medicare, Medicaid, and Marketplace Managed Care and has led teams in risk, quality, telehealth, and population health analytics.  Laura demonstrates effective leadership, innovative problem-solving techniques, and goal-oriented focus to execute business objectives and meet performance metrics.  Laura designed and coordinated activities including provider education, training, auditing, data mining, and data analysis to direct program success and achieve all risk goals.  Laura is also a certified professional coder and a certified risk coder. 

Susan L. Waterman Director, Risk Adjustment

Baylor Scott and White Healthcare 

As Director of Risk Adjustment, Susan Waterman has been empowered to plan, design and oversee business and strategic objectives in creating and optimizing a Risk Adjustment Department responsible for ensuring the accuracy of risk adjustment payments while successfully managing all activities related to Medicare Advantage, ACA and Exchange Risk Adjusted lines of business. In that capacity Susan directed department changes that resulted in multi-million dollar gains in Risk Adjustment, brought all chart review activity in-house, and partnered with the hospital CDI/Quality Physicians to create an Outpatient CDI Department focused on documentation quality, Risk Adjustment activities and clinic training.

A proven leader in her field, Susan’s professional experience includes coding and compliance management, auditing and provider training, system management, and consulting services.