Maria Mojica

• Ensure compliance with contractual requirements with federal and state government reporting and regulations
• Manages HPMS memos communications and ensures they are individually analyzed, assigned, and completed
• Ensures timely submission of Regulatory communications
• Assists with implementation of the compliance program that effectively prevents and/or detects violation of applicable laws and regulations, which will protect the Business from liability of fraudulent or abusive practices
• Ensures the Business understands and complies with applicable laws and regulations pertaining to Global Health plan
• Spearheads development and implementation of compliance policies and procedures and training programs for Global Health
• Responsible for periodic audits including ODAG, TMP and the yearly Parts C and D Data Validation audit
• This includes reviewing Universe integrity testing, Scope completion, Audit Webinars, Corrective Action Plans, and Exit Audit meetings
• Investigates and resolves compliance problems, questions, or complaints received internally or from customers/agencies
• Provides input and representation on key compliance initiatives, meetings, and committees, including monthly Compliance Committee
• Assists in yearly review of yearly model materials, including ANOC, EOC, ANOC Errata, and EOC Errata.
• Analyzed all audit results and resolved all compliance issues.
• Prepared reports for templates and maintained compliance database.
• Prepared working papers, reports and supporting documentation for audit findings.
• Participated in various training and development programs.

• Ensure compliance with contractual requirements and federal and state government reporting and regulations
• Maintain government relations for compliance activities
• Ensure compliance with contract provisions with various agencies and applicable State and Federal laws
• Serve as compliance resource for day–to-day processes
• Analyze and determine the best course of action for each inquiry/problem
• Act as primary contact for initiating and coordinating compliance projects
• Develop and update plan policies and procedures to ensure compliance with federal and state requirements
• Conduct periodic assessments and audits to ensure compliance with contractual and regulatory requirements and timeliness of submission
• Oversee the day-to-day health plan policies and procedures to ensure federal and state regulatory compliance
• Preparing affidavits, legal correspondence, and other documents for the External Affairs Department
• Organizing and maintaining documents in a paper or electronic filing system
• Coordinating legal activities, including Submission of completed Subpoenas
• Gathering and analyzing statutes, decisions, and legal articles, codes, documents, and other data
• Ensuring compliance for the Medicaid Fair Hearing Process.
• Supported team by pitching in to complete special projects.
• Performed quality reviews to uncover workflow and communication issues.
• Directed and implemented strategic improvement plans to integrate solutions to audit findings and workflow process issues.

• Analyzes patient records to determine legitimacy of admission, treatment, and length of stay in health-care facility to comply with government and insurance company reimbursement policies
• Analyzes insurance, governmental, and accrediting agency standards to determine criteria concerning admissions, treatment, and length of stay of patients
• Managing and performing timely authorization requests for inpatient admissions and concurrent reviews with various Managed Behavioral Health Organizations to ensure extended stays are medically justified
• Compares inpatient medical records to established criteria and confers with medical and nursing personnel and other professional staff to determine legitimacy of treatment and length of stay
• Identifies problems related to quality of patient care and refers such problems to the Quality Assurance Committee
• Abstracts data from records and maintains statistics such as Peer to Peer reviews, type of admissions, length of stay to determine trends
• Assists review committee in planning and holding federally mandated quality assurance reviews
• Responsible for the implementation of new processes and procedures for the Appeals and Retrospective review process
• Manages and develops training and job aides pertaining to Appeals and Retrospective reviews
• Responsible for developing, implementing, and administering process improvement projects for Appeals and Retrospective review process including, internal workflows and standard operating procedures to ensure best practices are being followed
• Work with other internal departments as necessary to meet timely processing of appeals, denials, and retrospective reviews.
• Performed prior authorization review of services requiring notification.
• Evaluated medical guidelines and benefit coverage to determine appropriateness of services.
• Submitted cases for criteria failures and helped facilitate resolutions and approvals.
• Obtained authorizations from multiple insurance carriers for various levels of care.
• Performed admission reviews based for medical necessity.
• Supervised and maintained all utilization review documentation through EPIC.
• Facilitated workgroup meetings with medical personnel to find effective solutions to issues.
• Established and maintained effective communication with staff, physicians and community organizations to promote high quality patient care.

· Manages the Appeals staff to ensure all key functions of the Appeals department are organized, timely and accurate in accordance with internal policies and procedures, federal and state regulations (including AHCA), NCQA MBHO Standards and URAC Health UM Standards

· Extensive knowledge of Medicare, Medicaid, and Commercial MBHO lines of business

· Responsible for the development and maintenance of quality control processes for the Appeals department, to ensure NCQA, MBHO and URAC Health UM standard turnaround times is consistently met

· Work with other internal departments as necessary to meet timely processing of appeals, denials, and retrospective reviews

· Support assigned quality committees through comprehensive evaluation of interventions, ensuring that documentation is accurate/timely, agenda items presented, and follow-up taken

· Review, analyze, and create detailed documentation of business requirements and systems functionality; including workflows, program functions, and recommendations to develop or modify systems and/or applications for the Appeals Department

· Develop test Appeal cases, perform initial testing, support end-user testing, document findings, and make recommendations/prepare business requirements accordingly

· Daily direct supervision of all Appeals department staff, including training and coaching

· Responsible for the implementation of new processes and procedures for all Appeals department staff

· Manages and develops trainings and job aides for all Appeals department staff

· Responsible for developing, implementing, and administering process improvement projects for the Appeals department

· Oversight responsibilities for Appeals department internal workflows and standard operating procedures to ensure best practices are being followed

· Responsible for identifying the appropriate modifications to processes and operating procedures in order to meet regulatory and accreditation requirements within the Appeals department

· Develop and implement strategies to ensure accurate and timely reporting of data

· Oversees all Incoming Quality Control and Continuous Improvement activities; provides guidance and expertise to project teams and continuous improvement “consulting” services to internal customers

· Conducts qualitative and quantitative analysis of all quality data in the Appeals department and reports results to the Quality Committee

· Develop annual, semi-annual, quarterly, and ad-hoc reports, and reports them to the Quality Committee, as well as external clients

· Responsible for internal review audits to ensure regulatory and accreditation compliance is met in the Appeals department

· Completed documentation and organization of client audits, national accreditations, and internal audits for the Appeals department

· Maintains annual and/ or coordinates revisions to the Corporate Appeals policies and procedures in coordination with the Corporate Director of Policy Management to ensure the Appeals policies and procedures are in accordance with federal and state regulations (including AHCA), NCQA MBHO and URAC Health UM Standards.

· Assisted in completion of the annual Quality improvement documents (including work plans, program descriptions, and annual evaluations)

· Responsible for tracking of complaints, grievances, adverse incidents, and quality of care concerns; coordinating with appropriate support staff to ensure compliance with customer expectations

· Responsible for Inter-Rater Reliability studies and any other Quality Improvement studies conducted as required for assigned contracts or customers, both internal and external.

· Works closely with the appropriate staff to establish and maintain a performance measurement/indicator system for Operations

· Conduct analyses of data findings for quality and process improvement and assist in report preparation for internal and external customers

· Assisted in the organization of Miami Service Center Quality Improvement Committee including meeting agenda, PowerPoint presentation, and meeting minutes.

· Provider coordination of care survey and other quality department surveys