Karla Mills

• • Managed the intake, review, and coordination of Complaint Tracking Module (CTMs) complaints for CMS, ensuring timely and accurate resolution in compliance with CMS standards.
• • Provided oversight for documentation processes, ensuring consistency and compliance with regulatory requirements.
• • Led the team in developing and implementing quality control measures to enhance the accuracy and efficiency of case management workflows.

• • Performed comprehensive Quality Assurance assessments of Medicare member materials, meticulously proofreading, editing, and verifying compliance with CMS Marketing Materials models and Source of Truth documentation
• • Coordinated the timely processing of documentation for Medicare programs, meeting strict CMS timeline requirements..

• • Reviewed medical records to close HEDIS care gaps, maintaining a 97% accuracy rate while ensuring efficient workflow.
• • Conducted "Over-reads" audits to ensure the quality and consistency of abstracted medical records.

• • Performed comprehensive Quality Assurance assessments of Medicare member materials, meticulously proofreading, editing, and verifying compliance with CMS Marketing Materials models and Source of Truth documentation
• • Ensured timely and accurate documentation and mailing of materials in line with CMS requirements.

• • Managed communication with patients diagnosed with COVID-19, providing health education and guidance on quarantine procedures.
• • Conducted epidemiologic investigations and ensured accurate documentation in authorized systems.

• Revamped the organization's complaint and grievance system, categorizing complaints to improve patient care and reducing response time by 15%.
• Managed audits and compliance assessments for various healthcare grants, ensuring adherence to state and federal regulations.
• Led quality initiatives, including HEDIS Medical Records Requests and Risk Adjustment chart abstraction, maintaining compliance with CMS, HRSA, NCQA, HEDIS, and PCMH standards.
• Collaborated with cross-functional teams to develop and implement targeted solutions for identified quality issues, ensuring continuous improvement.
• Provided detailed reports on quality metrics to senior management, enabling informed decision-making regarding process improvements.

• Led the monitoring and auditing of Appeals and Grievances and Medical Management, ensuring compliance with CMS Medicare Advantage (Part C) guidelines.
• Developed and implemented internal auditing tools to prevent, detect, and correct problem areas, maintaining readiness for CMS external audits.
• Provided project leadership for compliance-related audits, overseeing departmental policies, workflows, and monitoring efforts.

• Conducted regular reviews of company policies and procedures for alignment with regulatory requirements and industry best practices.
• Stayed current with latest changes to applicable regulatory standards and company procedures.
• Streamlined internal audit processes for improved efficiency and accuracy in detecting potential compliance issues.