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. • Verified E Load process was correct in all systems for membership and completed accurately in all databases generated from automated 834 against FACETS systems.• Responded to enrollment verification requests and updated accordingly.

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 results.• 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.• Directed periodic NCQA file reviews for reaccreditation and presented audit findings and opportunities for improvement.• Coordinated with the leadership team to achieve corporate savings, incentivize improved quality of care, and establish approved Payment and Clinical Policies.• Advised in interviewing process, performed preliminary candidate screenings through resume review and made recommendations to hiring managers. • Identified and compiled data to justify new positions in the appeals department.• Trained staff on assembling cases for Arbitration and State Fair hearings for our compliance department.• Revised Member Rights and policies for appeal resolution time frames for all Medicaid and Ambetter lines of business affecting 15+ staff members.• Established a new Appeal Training Manual to clarify and define current appeal procedures.• Controlled and renewed member and provider letters to ensure strict compliance with OMPP and NCQA regulatory requirements.• Reviewed and processed ER (emergency room) Appeals as a Prudent Layperson.

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.• Articulated project specifications, defined project scope and identified individual responsibilities at each phase of the project.• Reviewed data analyzed reports and progress toward meeting project objectives and recommended modifications as appropriate.• Participant and contributor to initial NCQA accreditation and subsequent reaccreditation efforts.• Investigated and compiled data for annual EQRO surveys and related activities.• Collaborated with various departments to update and manage the OMPP QI Work plan.

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.• Tracked and coordinated various projects to ensure activities met specified goals.• Developed and supported an appeal recording system to keep compliant with NCQA and state contractual timeline requirements. • Educated members and providers on submitting correct documentation for appeal submissions.