Karla Mills Email & Phone Number

Houston, Texas Area

Maintain awareness of legislative and regulatory activities related to health care and disseminate information to appropriate partiesEvaluate clinical data and use continuous quality improvement principles and tools.Conduct concurrent/retrospective reviews for the purpose of identifying opportunities for improvement in the delivery of patient care and supporting departments to ensure compliance with federal, state, local and accrediting agency regulatory requirementsUse statistical analytics to coordinate data collection and trend analysis for process and health outcomes and compare and contrast identified objectives. .Uses data to evaluate process improvement and reports findings to appropriate team members.Conducts complaint/grievance investigations, medical record reviews, and reviews for clinical studies and/or quality of care investigations and reports findings in appropriate department heads.Participates in ongoing educational opportunities such as conferences, workshops, symposiums and lectures related to performance improvement and clinical quality improvement.Prepare and present quality of care reports to the Quality Committee or other committees and meetings as assigned.

Houstontx,

Plan, lead and manage multiple concurrent internal and external audits.Assist the Pharmacy team in implementing appropriate QA reporting of Medicare Part D Coverage Determinations (CD), Redeterminations and Grievances monitoring exercises.Providing guidance and oversight with the development of Part D Policy and Procedures, SOPs, audit tool and the QA audit, contributing to the 1st report introduced to the Pharmacy Benefit Manager (PBM) Coverage Determination Appeals and Grievances (CDAG) team.Responsible for identifying and prioritizing significant compliance risks to report to the Compliance Audit Management Team and key executivesReview and evaluate the effectiveness of corrective action plans that address audit report findings and provide guidance to Senior Management and Compliance Oversight Committees.Provided regulatory and compliance guidance while participating on various project management teams to assist with company sanction remediation initiatives.Subject matter expert to business units to identify and investigate compliance risks and establish appropriate courses of resolution.Participated in multiple CMS and internal audits through audit planning and related projects, developed objectives, scope, and ensured efficient and effective audit execution.Provide project leadership for compliance related audits, including the review of departmental policies and procedures, department work flows and departmental monitoring efforts.Preparation of all monitoring Senior Leadership Reporting, i.e. Compliance Committee and Delegation oversight, and Monthly Corrective Action Plan reporting

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