GINA ORTIZ
Trujillo Alto
Summary
Versatile Compliance Auditor with an understanding of operations in the health insurance industry. Proficient in reading, interpreting and implementing federal and local regulations. Creative, versatile professional with a diverse work experience and great at project management. Flexible and strong problem-solving skills in fast-paced, ever-changing environments. Efficient with focus on high-quality content under tight deadlines.
Overview
14
14
years of professional experience
Work History
Compliance Auditor
Triple-S Salud
01.2023 - Current
- Collaborated with cross-functional teams to ensure timely implementation of corrective actions, mitigating potential compliance issues.
- Plan and develop the audit approach for assigned projects consistent with ASES, CMS state guidelines, Commercial and Medicare Advantage policies and procedures and in accordance with the timeframes established by the management.
- Track open audit and monitoring issues and perform follow up to evaluate timeliness and adequacy of remediation efforts.
- Provide compliance performance feedback to internal business units.
- Produce high quality audit and monitoring reports for management, and in compliance with CMS regulatory requirements.
- Monitor the Compliance Company-wide monitoring tool, including but not limited to Compliance Dashboard and/or Compliance Scorecard.
- Conduct review of information provided by internal departments for regulatory agencies oversight activities. Ensures the information complies with the regulatory agencies requirements, identify and communicate to the management any associated risk.
- Responsible to manage, validate and submit regulatory reporting requirements.
- Support and execute the communication, coordination, validation and submission of information regarding Regulatory Agencies Oversight Activities.
- Supports the distribution of tasks through the Compliance 360 application and follow up on action items.
- Analyzed all audit results and resolved all compliance issues.
Quality Specialist I – Appeals & Claims Auditing
Centene Corporation
03.2022
- Perform quality reviews to ensure high level of customer service and/or accuracy in processing claims and transactions
- Conduct procedural and quality reviews/audits to ensure adherence to policies and procedures and high levels of customer service, satisfaction and accuracy using applicable tools and technologies
- Provide written documentation to management regarding quality review/audit results
- Collaborate with various cross functional departments to identify training needs, system errors, processing errors, etc
- And develop work plans and processes
- Participate in continuous quality improvement initiatives and serve as a resource to others regarding quality concerns
- Analyze data to ensure adjustments/changes yielded anticipated results
- Assist with managing databases, policies and procedures related to assigned areas
- Complete special projects as needed.
Educational Aide
Birdville Independent School District
09.2016 - 12.2021
- Assists in management, discipline, performance and teaching of students and any other duties assigned by classroom teacher
- Provide supplemental support to students in mastering content and performance standards in core content subjects
- Assists in teaching students in small groups or individualized settings
- Assists with classroom tasks as directed by teacher
- Implements classroom management procedures in absence or at request of teacher
- Encouraged dynamic and pleasant educational environment by promoting both gentle discipline and cooperation
- Oversaw students in classroom and common areas to monitor, enforce rules and support teacher.
Assistant Teacher
The Children's Courtyard
04.2014 - 05.2015
- Responsible for assisting lead teacher with implementation of brands curriculum
- Assist lead teacher in implementing daily program for children
- Help to maintain fun and interactive classroom that is clean and organized
- Ensure daily care of every child by following all licensing guidelines and implementing all company standards
- Provided one-on-one and group-based learning support to maintain student progress and development.
Senior Quality Specialist
First+Plus
02.2013 - 09.2013
- Implement and monitor strategies to accomplish work plans and goals established in Quality Department
- Lead quality health clinics projects to promote annual preventive screenings for Medicare members
- Make sure departments comply with standards of quality services and promote initiatives developed to improved star rating measures
- Develop and revise letter, presentations, reports, policies, and procedures related to quality projects
- Communicate policies and changes to operational areas impacted
- Conduct meetings in coordination with quality management about projects assigned
- Provide training to quality specialists and coordinators related to diverse regulatory matters and operational processes.
Compliance Specialist
MAPFRE Insurance
10.2012 - 01.2013
- Develop compliance department policies and procedures
- Direct experience working with federal and state agencies audits
- Monitor operational departments within organization and audit delegated entities (vendors).
Regulatory Affairs Specialist
Medical Card System (MCS)
07.2010 - 09.2012
- Review, analyze and send CMS mandatory guidelines to all departments
- Review company’s policies and procedures to ensure CMS guidelines were applied
- Carry out monitoring and audits of Corrective Action Plans and track compliance findings for needed remediation
- Answer inquiries regarding departments operational processes and its compliance with federal and state laws
- Provide compliance input on business action plans, projects and/or operational requests
- Monitoring CMS guidelines were implemented on the Grievances and Appeals department
- Review of CMS ODAG audit reports
- Ensure all enrollment marketing materials comply with annual benefits submissions
- Provide insight and guide management on compliance issues to all departments in the company
- Ensures proper implementation of compliance requirements and identify outstanding issues in the company.
Education
Master's Certification - Communications
University of The Sacred Heart
San Juan, PR01.2011
Bachelor of Arts - Communications
University of Puerto Rico
San Juan, PR01.2004
Skills
- Medicare Quality Standards
- Appeals/Claims Audits
- Medicare Advantage expertise
- CMS regulatory guidelines
- Group and individual instruction
- Fully bilingual (Spanish/English)
Timeline
Compliance Auditor
Triple-S Salud
01.2023 - Current
Quality Specialist I – Appeals & Claims Auditing
Centene Corporation
03.2022
Educational Aide
Birdville Independent School District
09.2016 - 12.2021
Assistant Teacher
The Children's Courtyard
04.2014 - 05.2015
Senior Quality Specialist
First+Plus
02.2013 - 09.2013
Compliance Specialist
MAPFRE Insurance
10.2012 - 01.2013
Regulatory Affairs Specialist
Medical Card System (MCS)
07.2010 - 09.2012
Master's Certification - Communications
University of The Sacred Heart
Bachelor of Arts - Communications
University of Puerto Rico
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