Sandra Mathis Email & Phone Number

• Conducted quality audits supporting the East/west region of 13 States.
• Generated weekly/ monthly reports of audit findings providing feedback to management.
• Substantiated Completeness and logic by auditing and processing electronic applications through EDS, FACETS and FEET systems.
• Met individual productivity metrics, quality and timeliness standards by department guidelines
• Analyzed and resolved errors resulting from automated file updates.
• Monitored, processed, and reconciled receipt of State enrollment files.

Saint Louis, MO, US

• Achieved the development and construction of the Grievance Database to enable and improve reporting capabilities and accessibility, for the grievance processing team.
• Produced all reports for the grievance, appeals, and various departments.
• Conveyed our departmental and NCQA goals and expectations for the Appeals Department to employees, stakeholders, and management through presentations and shared written feedback from quarterly and NCQA appeal audit.
• Over 5 years’ experience working with NCQA, and State regulatory agencies.
• Consulted in appeal team meetings providing updates and identification of process barriers.
• Conducted internal quarterly NCQA appeal audits substantiated by a match score of 90% interrater reliability.

Indianapolis, IN, US

• Managed annual Fluvention Project that resulted in a 32% increase in employee involvement with no noticeable impact on quality.
• Designed and implemented a paperless and streamlined process for the Pay for Performance program initiative.
• Utilized knowledge of HEDIS specifications, for medical record review process working with chase data analysis for HEDIS rates.
• Improved processes and designed workflows for departmental staff.
• Maintained and updated databases for tracking MD reviews.
• Administered departmental training for employees on new processes related to HEDIS® data collection and new employee orientation.

Indianapolis, IN, US

• Engaged in the restructuring of appeals department reducing the turnaround time of appeals processing from 73 days to 10 days.
• Aided in the development of a process flow for Quality of Care and Quality of Service
• investigations.
• Assembled information for QOC/QOS and member Complaint cases for review.
• Prepared reports and deliverables on projects for management staff.
• Monitored activities for compliance with company and government policies.