Specialist Medical Quality Auditor
Resume:
Sonya Aguilar
Qualifications Profile
Consistently works in dynamic and challenging environments; accustomed to collaborating with the team to achieve common goals. Promotes open interactive communications throughout the organization in an effort to gain understanding of all processes and increased knowledge. Thrives in developing effective resolutions, identifying issues, driving new initiatives, evaluating trends and risks. Possess good intellectual and interpersonal skills as evident through handling increasing job assignments and responsibilities. Exhibits technical experience in EAA, Aerial, Bluestar, Dashboard and ECM. Part of the successful reaccreditation for both URAC and NCQA.
Core Competencies
Business Development
Customer Service and Relations
Relationship Building
Continuous Process Improvement
Action Plans and Analysis
Problem Resolution and Decision Making
Career Highlights
Currently working on Accreditation Renewal for BCBSTX HMO Marketplace 2023 submission
Submitted a Successful Resurvey HMO Marketplace BCBSTX September 2020
Currently working on Renewal for BCBSIL HMO/PPO COMMERICAL/MARKETPLACE PPO MARKETPLACE 2022 Submission
Developed Audit tool for the Sr Accreditation Coordinators
Submitted a Successful Survey for BCBSNM JUNE 2020
Submitted a Successful Resurvey for BCBSIL JUNE 2019
Established exceptional growths of the BH Appeals department since go live.
Professional Experience
Blue Cross Blue Shield of Texas Richardson, TX August 2018-Current
NSR Accreditation COORDINATOR
Responsible for operations compliance with accreditation and regulatory requirements in assigned areas. Monitor staff performance regarding federal, corporate and accreditation standards and guidelines.
Participate in quality initiatives and department initiatives related to NCQA and URAC .
Responsible for developing, coordinating, integrating, and monitoring accreditation activities and initiatives in compliance to state and federal regulations.
Act as subject matter expert, handle complex assignments, and may assist training/mentoring department staff
Blue Cross Blue Shield of Texas Richardson, TX
N Quality Review Specialist Medical OPERATIONS APPEALS August 2017- August 2018
Responsible for facilitating Member and Provider Appeals; working closely with Full-Service Unit (FSU).
Work with provider Telecommunication Center (PTC), and Medical Management Department (MMD) to ensure appeal process meets established guidelines; adhering to accreditation and regulatory requirements.
Participating in department initiatives related to NCQA and URAC audits, DOI audits, revision project, audits, and correspondence revision projects; and managing individual inventory through appropriate workflow.
Blue Cross Blue Shield of Texas Richardson, TX
N Supervisor behavioral health appeals September 2013- 2017
Develop and maintain departmental policies, procedures, practices, and standards related to appeals compliance.
Monitor staff performance in regard to federal, corporate and accreditation standards and guidelines.
Participate in quality initiatives and manage department initiatives related to Department of Insurance NCQA and URAC audits.
Blue Cross Blue Shield of Texas Richardson, TX
N Behavioral Health appeals Coordinator September 2010– September 2013
Reviewed behavioral health appeals and IERs to prepare for review by Appeal Reviewer.
Complete facility and member call backs in regard to appeal rights
Complete expedited and standard appeal letters.
Ensures members and providers understand the appeals process through verbal and written communication.
Magellan Behavioral Health Richardson, TX
N Quality Auditor May 2008 - September 2010
Maintained and monitored quality assurance for member services are according to policy regulations.
Provided coaching and resource tools to ensure that true quality performance was being delivered.
Examined processes for best practices.
Facilitated Monthly meetings with leadership and prepared monthly and quarterly reports .
Magellan Behavioral Health Richardson, TX
N Appeal Coordinator March 2006–May 2008
Processed clinical and non- clinical appeals according to URAC and NCQA standards.
Contact and respond to members and providers within the state regulated turnaround times.
Prepared records and files for the external review process
Gathered records and files to prepare for URAC and NCQA audits.
Education
Associates in Child care Management i
Southwest Technical Institute of San Marcos San marcos, TX
High school Diploma
Central High School San Angelo, TX
References available upon request
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