Quality Assurance Auditor Healthcare Compliance and Analytics

Alyssa Garcia

Quality Assurance Auditor

916-***-**** ************@*****.*** Loomis, CA

Career Summary

Experienced and detail-oriented Quality Assurance Auditor with over 8 years in healthcare operations, specializing in Auditing, Appeals and Grievances, Clinical Operations, Claims Operations, Call Center, and Customer Experience. Proven ability to assess quality, including calls, ensure compliance with legal and contractual standards, and drive performance improvements through coaching and collaboration. Skilled in interpreting complex documentation, managing audit deliverables, and facilitating calibration sessions to align with organizational goals. Adept at using Verint, Facets, Auth Accel, and Microsoft Office tools to generate actionable insights and support strategic initiatives.

Technical Skills

Quality Assurance Auditing Commercial Appeals & Grievances Compliance DMHC & CDI Regulations Mandates Desk Level Procedures (DLP) Adherence Audit Findings & Trend Analysis Performance Coaching & Staff Development

Cross-Functional Collaboration Process Improvement Meeting Facilitation Quality Reporting Action Planning Vendor Coordination Health Plan Operations (Claims, Inquiry, Enrollment, Clinical, Non-Clinical, Mandates) Healthcare Call Experience Customer Experience Medical Terminology Strong Verbal & Written Communication Attention to Detail & Accuracy Critical Thinking Problem Solving Independent Judgment Time Management Multi-tasking Facets AuthAccel Verint Quality Assessment Systems Microsoft Office Suite – Excel, Word, Outlook, PowerPoint Work Experience

Quality Assurance Auditor, Advanced Blue Shield of California Nov 2022 – Present

• Conduct routine audits for Commercial Appeals and Grievances Department to ensure regulatory compliance.

• Audit multiple business areas including Pharmacy, Eligibility, Clinical, Non-Clinical, and Intake, ensuring accuracy, adherence to Desk Level Procedures (DLPs), and quality standards.

• Identify and document audit findings, care gaps, and compliance risks; escalate critical issues as needed.

• Provide coaching and feedback to front-line staff to improve quality outcomes.

• Analyze audit data to drive performance improvement and operational compliance.

• Collaborate with business and Quality Assurance leadership to ensure consistent messaging, support performance development, and meet organizational quality goals.

• Contribute to departmental and enterprise-level quality initiatives, including mock audits and process improvement projects.

• Facilitate calibration meetings and conduct real-time audits in collaboration with Appeals and Grievance leaders to ensure consistency, identify coaching opportunities, and support ongoing quality alignment. Appeals and Grievance Coordinator Blue Shield of California June 2018 – Nov 2022

• Manage appeal inventory for multiple teams including Pharmacy, Intake, Clinical, Eligibility, Non-Clinical and Executive Inquiries, ensuring compliance with regulatory guidelines, State Mandates, and HIPAA regulations.

• Research/resolve complex appeals, apply knowledge of health policies, benefits, and resolution procedures.

• Utilize claims processing knowledge including adjustments, interest accuracy, and back-end claims resolution.

• Demonstrate flexibility and adaptability, prioritizing workload to meet compliance and project deadlines.

• Identify misrouted cases and proactively address potential compliance risks.

• Provide peer support as a team mentor to help clarify workflows and improve performance.

• Exceed quality and productivity metrics, while adapting to evolving business needs and regulatory changes.

• Communicate effectively with doctors and directors to formulate ideas streamlining AB347 Mandate process.

• Coordinate with internal and external business partners to support case review and resolution. Appeals and Grievance Phone Team Blue Shield of California June 2017 – June 2018

• Answer high volume of inbound calls and initiate outbound calls; meet and exceed performance metrics.

• Assist with processing appeals by taking initiative/ownership of other coordinator’s cases.

• Ensure compliance with regulatory guidelines, state mandates, deadlines, and HIPAA standards.

• Coordinate with internal teams (Intake, Eligibility, Mandates, Clinical, Non-Clinical) supporting case resolution.

• Deliver exceptional customer experience results, including call de-escalation. Claims Member Level Processor Aerotek – Blue Shield of California Feb 2017 – June 2017

• Review claims for payment accuracy against procedural documentation and State Mandates.

• Draft clear, professional Medicare denial letters to members and providers regarding services rendered.

• Track data in excel spreadsheets and databases.

• Request medical records from providers.

Caregiver In-Home Supportive Services May 2016 – Feb 2017

• Ensure quality customer service for clients and deliver a high level of care.

• Display a high level of empathy and patience for others.

• Observe and report changes in health conditions.

• Transportation to and from appointments.

Member Service Representative Health and Life Organization July 2015 – Aug 2016

• Answer high volume of inbound calls and initiate outbound calls.

• Verify insurance eligibility, including experience with Medi-Cal.

• Schedule medical and dental appointments according to procedural documentation and templates.

• Maintain confidentiality while adhering to HIPAA regulations. Resident Assistant Brookdale Senior Living Feb 2011 – July 2015

• Ensure quality service for clients and families, delivering a high level of care, while communicating effectively

• Observe and report changes in health conditions and maintain proper care records.

• Provide essential and excellent care for residents with activities of daily living. Education and Certification

Certified Nurse Assistant Training & Home Health Aid Kash Career College High School Diploma Center High School

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