Carol Soto
Corporate Compliance - Audit & Compliance @Healthfirst
Signup · Get unlimited contacts
WORK HISTORY
Corporate Compliance - Audit & Compliance @Healthfirst
New York, NY, US
Developed and implemented a comprehensive Compliance Program for Mental Health Parity, ensuring adherence to regulatory requirements and promoting equitable access to mental health services.• Spearheaded the development and implementation of a compliance program to align with evolving regulatory requirements, safeguarding organizational integrity.• Established and implemented robust metrics to monitor key business areas, facilitating proactive oversight of regulatory compliance and ensuring audit readiness. Effectively developed monitoring systems to track adherence to regulations, minimizing compliance risks and ensuring seamless audit processes. Regularly reported outcomes to Senior Leadership and Compliance Committees.• Collaborated with cross-functional teams to integrate compliance considerations into business processes, contracts, and vendor agreements, fostering consistent compliance throughout the organization.• Participated in and led corrective action improvements resulting from internal and regulatory audits, optimizing compliance outcomes.• Identified reporting gaps, leading to the creation of tighter performance metrics in vendor contracts, resulting in improved compliance metrics and decreased occurrences of findings in regulatory audits.• Reviewed new and existing vendors\' compliance plans, ensuring alignment with organizational standards, resulting in successful partnerships.• Initiated and developed comprehensive corrective action plans to address non-compliance issues, effectively resolving compliance challenges.• Managed the compliance hotline for anonymous complaints and actively participated in investigations, leading the Compliance Complaint Committee to ensure prompt and compliant resolutions. Consistently enforced disciplinary actions in accordance with compliance standards.• Conducted thorough risk assessments to identify compliance gaps and areas of vulnerability within the organization.
EDUCATION
Southern New Hampshire University
Bachelor of Business Administration - BBA, Health/Health Care Administration/Management
SKILLS
ABOUT CAROL SOTO
Experienced healthcare professional with over two decades of expertise in health insurance compliance and operational management. Deep understanding of industry dynamics and regulatory trends, enabling strategic execution of policies and procedures to ensure compliance. Skilled in building cohesive teams of clinical and non-clinical professionals, both in-office and virtual, fostering unity and teamwork to drive successful departmental outcomes.Accomplishments:•Maintained a 5 Star Rating for 6 consecutive years on Appeal Metrics: Fairness of Decision Making and Processing Timely Appeals. •Improved and revamped A&G processes to meet timeliness requirements; maintained monthly average of 98% and above for resolution timeliness for appeals, complaints, and grievances across Medicare, Medicaid, and Commercial products for 1.4 million membership plan. •Remediate Appeals & Grievances processes and audit universe data to meet compliance and obtain a successful regulatory audit outcome within 7 months from the initiation of corrective action plans from regulators. •Spearheaded efforts to move multiple on-site resources to a virtual workspace. Built customized processes and platforms to effectively monitor virtual workers.•Coordinated, designed, and implemented business process management platforms to streamline A&G workflows and to enhance reporting.•Implemented a strategic delegated vendor compliance oversight and monitoring plan to ensure proper processes are in place, service level agreements align to regulations, and regulatory compliance is met. •Successfully hired, trained, mentored, and coached entry-level staff into managerial staff. Key Skills & Abilities:• Proactively identify strategic opportunities to mitigate company exposure to external risks, ensuring the organization\'s stability and resilience.• Foster collaborative partnerships with multiple departments, promoting consistent communication and delivering exceptional experiences for members and providers alike.• Drive innovation by creating cutting-edge tools and processes that not only ensure regulatory compliance but also set industry benchmarks within the organization.• Excel in developing, managing, and mentoring individuals, guiding their growth into leadership positions and cultivating a strong talent pipeline.• Build high-performing teams characterized by integrity, dedication, and a shared commitment to advancing the company\'s best interests.
This profile is compiled from publicly available professional sources. Unifers is not affiliated with or endorsed by LinkedIn. Request removal of this profile.