Adriana Tapia
Granada Hills,CA
Summary
UM compliance and audit professional focused on referral and authorization oversight, documentation control, and health plan requirements. Brings hands-on experience with internal quality reviews, external audit coordination, compliance committee support, and process improvements tied to turnaround times, training, and reporting accuracy.
Overview
1
1
Language
15
15
years of professional experience
Work History
UM Compliance Auditor
MedPOINT Management
Sherman Oaks, CA
05.2017 - 10.2026
- Conduct internal quality assurance reviews of referral and authorization processes to ensure accuracy, consistency, and compliance with regulatory and operational requirements.
- Prepared and submitted referral and authorization logs, case files, medical records, and supporting documentation to meet Health Plan audit requirements.
- Serve as the primary liaison to Health Plan Oversight Auditors, coordinating audit requests, documentation submissions, and follow-up activities.
- Coordinated departmental assignments and facilitated timely responses to Health Plan documentation and audit requests, ensuring compliance and efficiency.
- Prepare, analyze, and distribute monthly referral and authorization reports, monitoring processing accuracy, turnaround times, and operational performance.
- Identify staff training needs and provide training to team members and providers regarding referral and authorization procedures, including DMHC Sterilization Consent Form requirements.
- Participate in Compliance Committee meetings, contributing to discussions and initiatives related to regulatory compliance and operational improvements.
- Maintained records and tracking logs of Health Plan audit results, identifying trends to support process improvement initiatives.
- Develop, maintain, and update Health Plan-required templates to ensure accuracy, consistency, and compliance with established requirements.
Auditor
LA Care
Los Angeles, California
04.2012 - 05.2017
- Conducted annual oversight audits and continuous monitoring for medical group plan partners, pharmacy vendors, pharmacy benefit management, and medication therapy management.
- Reviewed approval, denial, and appeal files to ensure compliance with 24-hour or 1-business-day turnaround times.
- Onsite chart reviews confirmed requirement compliance across reviewed records.
- Member records were audited for accuracy, completeness, and confidentiality standards.
- Provider documentation was examined against Medi-Cal and regulatory requirements.
- Drafted final audit findings and corrective action plans as necessary to address compliance issues.
- Mitigation responses and proposed corrective action plans from PPG or plan partners were reviewed and addressed.
- Pre-audit document request lists were created and revised to support audit preparation.
- Pre-audit document submission was verified with regulatory affairs and compliance before review by PPG or plan partner groups.
- Created and updated Excel spreadsheets to enhance organization and tracking of audit files.
- Audit findings were prepared for management and compliance review.
- Audit tools and spreadsheets were updated to strengthen NCQA compliance support.
- Injectable medication policies and procedures were validated as revised and approved within the past 12 months.
- Exigent deficiency forms were submitted for PPGs with repeat deficiencies.
- Utilized Welfare and Institutions Code Section 14185 for compliance assessments. was applied during audit review.
- Utilized California Health and Safety Code Section 1367.01 for regulatory review. was applied during compliance review.
- Analyzed committee minutes for accuracy and relevance to audit decisions. and determination guidelines were reviewed to support audit decisions.
- Corrective actions were tracked through LA Care audit follow-up and closure.
Education
Some College (No Degree) - Healthcare Administration
Southern New Hampshire University
Hooksett, NHSkills
- Utilization management oversight
- Regulatory compliance in healthcare
- Quality assurance processes
- Authorization and referral processes
- Health plan oversight audits
- Documentation for audit preparation
- Coordination of audits
- Tracking data effectively
- Data reporting and analysis techniques
- Improvement of processes
- Management of workflows and processes
- Collaboration across departments
- Participation in compliance committees
- Training and development of staff
- Standards for healthcare documentation
- Proficiency in Microsoft Office Suite
- Effective verbal and written communication
- Effective verbal and written communication
Languages
Spanish
Native/ Bilingual
Timeline
UM Compliance Auditor
MedPOINT Management
05.2017 - 10.2026
Auditor
LA Care
04.2012 - 05.2017
Some College (No Degree) - Healthcare Administration
Southern New Hampshire University