FRANKLIN GONZALEZ
Mcalpin
Summary
Results-oriented Performance Quality Auditor with a focus on healthcare compliance and auditing. Successfully identified compliance gaps and executed process enhancements, leading to improved operational outcomes. Expertise in data analysis and collaboration across functions to boost quality assurance. Strong background in team mentoring, promoting high standards in service delivery.
Overview
11
11
years of professional experience
Work History
Performance Auditor/Process Expert
HealthSun Health Plans/ Elevance Health
01.2018 - Current
- Conducts targeted compliance audits under the guidance of the assigned manager, ensuring adherence to regulatory, contractual, and internal requirements.
- Plans and executes audits, collects and verifies audit evidence, composes findings and conclusions, and assists in preparation for Centers for Medicare & Medicaid Services (CMS) site visits.
- Analyzes records, reports, regulations, and operational procedures to identify compliance gaps and areas for improvement.
- Assists in root cause analysis and development of corrective action/remediation plans based on audit findings.
- Maintains up-to-date knowledge of ODAG and CDAG audit processes and data requests.
- Collaborates with management to ensure compliance with federal regulations and industry standards.
- Tracks and trends audit results, providing feedback to management and identifying systemic issues affecting quality and compliance.
- Generates monthly audit reports, supports clients in addressing identified issues, and develops data-driven reports to assist management decision-making.
- Produces ad hoc reports as requested by internal and external stakeholders.
- Evaluates the accuracy and quality of transactions and communications with providers, groups, and policyholders.
- Identifies, documents, and reports transaction errors or communication issues promptly to facilitate resolution.
- Conducts routine to complex audits across multiple functions, system platforms, and lines of business to ensure compliance and operational efficiency.
Intake Specialist
Beacon Health Options
01.2016 - 01.2017
- Provided guidance to recipients, families, and providers regarding autism benefits, eligibility, and service authorizations.
- Facilitated coordination of care by contacting medical and behavioral health providers, ensuring appropriate follow-up for members transitioning from higher levels of care.
- Collaborated with Care Managers, Team Leads, Clinical Managers, and Peer Advisors through case consultations and rounds for cases requiring specialized attention.
- Participated in the Quality Management process by conducting regular audits of completed work to maintain compliance and service excellence.
- Conducted outreach to members and families, encouraging engagement with Peer Specialists for additional support when appropriate.
- Assisted with claims-related inquiries, resolved processing issues, and processed necessary claim adjustments.
Grievance & Appeals Specialist
Humana/Careplus Health Plans
01.2015 - 01.2016
- Provided guidance to recipients, families, and providers regarding autism benefits, eligibility, and service authorizations.
- Facilitated coordination of care by contacting medical and behavioral health providers, ensuring appropriate follow-up for members transitioning from higher levels of care.
- Collaborated with Care Managers, Team Leads, Clinical Managers, and Peer Advisors through case consultations and rounds for cases requiring specialized attention.
- Participated in the Quality Management process by conducting regular audits of completed work to maintain compliance and service excellence.
- Conducted outreach to members and families, encouraging engagement with Peer Specialists for additional support when appropriate.
- Assisted with claims-related inquiries, resolved processing issues, and processed necessary claim adjustments.
Education
Bachelor of Science - Criminal Justice
Florida International University
Miami, FL01.2012
Associate of Arts - Criminal Justice
Miami Dade College
Miami, FL01.2010
Skills
- Healthcare compliance & auditing (ODAG/CDAG, CMS regulations)
- Medicare Advantage & managed care expertise
- Training, development & mentoring
- Case management & member support
- Quality assurance & performance monitoring
- Data analysis & reporting
- Cross-functional collaboration
- Problem-solving & critical thinking
- Customer service & communication
- Organizational & time management
- Process improvement
- Data analysis
Languages
Fluent in English, Fluent in Spanish
References
- References are available upon request
Timeline
Performance Auditor/Process Expert
HealthSun Health Plans/ Elevance Health
01.2018 - Current
Intake Specialist
Beacon Health Options
01.2016 - 01.2017
Grievance & Appeals Specialist
Humana/Careplus Health Plans
01.2015 - 01.2016
Bachelor of Science - Criminal Justice
Florida International University
Associate of Arts - Criminal Justice
Miami Dade College
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