Catherine Estibaliz Pabon P

Transformational impact through management recommendations to shape quality systems according to the mandatory system of quality assurance establish by the Colombian Ministry of Health (SOGC) with focus in structural qualification and Audit process.
Verify, analyze and diagnose the structural qualification process designing improvement recommendations to adjust all the requirements applicable according to the standards establish in the Resolution 2003/2014 and all the rules that complement it or requests by Ministry of Health. Training, continuous escort and follow up during the process.

Position: Network Medical Auditor- IPS Calle 26, IPS Calle 94, Surgery Services, Partners -Contracted medical facilities, IPS Fontibon and IPS Suba

High impact in the Quality Improvement measurement framework management specifically in Continuity, Pertinence and Safe Practice indicators in the assigned Network to impact positively in the overall patient experience, aligning best-practices with cost-effective decisions and obtain the best clinical/non clinical outcomes.

 Implemented new outcome audit and restructured the Audit framework focused in prioritized indicators such Pertinence, Continuity and Patient Safety, enhancing the active assessment of medical staff and other related health disciplines, as well implementing active feedback process and improving the training tools/activities. Monitoring indicators performance, following up compromises for continues improvement optimizing the impact individually and the Compersar network.
 Successes of continuous improvement process in prioritized KPIs increasing their performance and maintained them above 80% to impact in the performance of patient experience.
 Implemented active Management Audit follow up to the network audit team to evaluate efficient activities/performance as well as measure the scope of activities and quality related committees in the Compensar Network.
 Monitored the performance in the Technical/Scientific evaluation of Health services in all the complexity levels of service to ensure adherence with government guidelines, protocols and compliance with clinical standards making effective feedback to medical staff and their managers.
 Participation in adjust and update of internal Clinical Practice Guidelines CPGs and clinical protocols to keep them aligned with international/accreditation standards and practices according organizational policies and patient center care principles.
 Perform quality evaluation at the Ambulatory Operating Theaters reviewing the application of SOPs and Safety- check list success implementation for safety procedures and transitions of care.
 Monitored the reporting of Adverse Event, Sentinel RCA and Critical Incidents in outpatient care and surgical services to make decisions and decrease effectively the frequency of Preventable Incidents.
  Prepare and develop obligatory Quality Committees according assigned tasks, as well as organize periodic reports to the High Management and participate in the Quality Council to present Audit outcomes, relevant indicators and related recommendations applied in the Improvement Action Plan and deployment to all medical areas.
 Support to Health Service Complains area to perform clinical investigations and coordinate a multidisciplinary committee to analyze specific medical legal cases.

Effective and success Pre-Authorization/Authorization claims process and bills recovery process due lack of Medical Pertinence, Prebilling review in situ to contain non pertinent cost and improve accuracy in the billing process according coverage policies and negotiation with financial high achievement in high cost diseases.


 Developed and monitored of comprehensive audit emphasizing high cost diseases from ICU and CICU in the central Network. Verifying clinical process and medical justification to impact with accuracy during in- patient services for prebilling process of the claims.
 Invoices medical reconciliation in first and second instance held for lack of medical pertinence in accordance to policies, contractual terms and health coverage in subsidiary regimen. Monitoring, training and coaching the technical team to control non-pertinent cost, detecting fraud and overcharging,
 Liaison with the National Network Providers to manage the pre-approvals and approvals of special treatments, procedures, medical activities and supplies in accordance of medical condition, policies, health coverage, CPGs adherence and cost-effectiveness.
 Quality Audit of providers contracted from primary care to high-complexity with a systematic evaluation of their clinical practice against guidelines and protocols to support and encourage improvement in their services. Monitoring corrective and improvement plans as well as verifying the reports of Mandatory Health Indicators to the Governmental Control Institutions.
 Monitoring KPIs performance in the Central Network and active evaluation of services offered/demanded according to the coverage required. Verifying Quality Indicators of the contracted Network such as patient satisfaction, waiting services, time-lapse response complaints, opportunity, morbidity-mortality indicators, Hospital Acquired Condition rates, readmissions and medical records quality.
 Audit of medical accounts checking the invoice commit/Credit notes in the medical reconciliation process according pertinence and medical coverage.
 Developed clinical investigation of special Medical-Legal Cases, clinical support to Complaint Area and to secure effective conciliation process.
 Developed feedback reports to enhance the supplier in good clinical practices, patient experience as well as billing process and then prepared the executive periodic report to our stakeholders and high management for further reviews and strategic decisions.

Development of integral Clinical Audit of the health services provided in hospitalization and out-patient enhancing an effective feedback to the medical and administrative staff, ensuring high quality in the process of care, optimal patient experience and accurate billing.

 Performed concurrent audit of treatments and medical procedures of high level complex, interaction with specialist, peers and other health staff/ ensuring an optimal experience in the care cycle and ensure medical justification clear in medical records.
 Organize the institutional Medical History Committee to evaluate the quality of medical records and develop the periodic feedback for continuous improvement.
 Perform investigation with RCA and issue Medical Concept in special Medical- Legal cases to the parties involved and organize the Ad -Hoc Committee if is required.
 Monitoring Adverse Occurrence and sentinel incidents and analyze the most relevant in committee with the parties involved.
 Negotiation during prebilling and billing process with the Insurance Auditor and develop first instance conciliation.
 Support the authorization team and handle the medical claims team of analysts overseeing an accurate process of billing and medical justification for reimbursement.

High optimization in the Audit Process Management and enhancement of the approvals of special claims (Non POS services) and Reimbursement process for Services Not Covered under the Health Obligatory Plan in Colombia - medical coverage (POS) and recoverable through Fosyga (Governmental payer).

 Medical Audit process management leading remote teams in the Regional assigned. Regional Conciliation and renegotiation of medical bills in second and third instance. Conduct data driven on-site audits of healthcare providers in the network contracted and ensure the evaluation of medical records, justification of claims, assess discrepancies in the pre-billing process performed by the medical team assigned in a regional area.
 ¨CTC¨ (Technical & Scientific Committee) management team to approve claims for procedures, activities and medical supplies not covered under the POS (Health Obligatory Plan in Colombia - medical coverage) through Fosyga (Governmental payer).
 Support the National Network contracted providing clear policies to compliance requirements for reimburse through this committee, improving best practice in processing this specials claims.
 Improvement of reimbursement process, pre checking mandatory requirements and improving commitments with stakeholders and internal areas related to enhance and secure payment by Fosyga.
 Support the National Network contracted providing clear policies to compliance requirements for reimburse through this committee, improving best practice in processing this specials claims.
 Organize workload for the medical and analysts team identified training and coaching needs, developing professional skills and maintain update all the internal guidelines to conduct the committee.
 Perform investigation with RCA and issue Medical Concept in special Medical- Legal cases to the parties involved.

Patient focused provider of primary medical care to different companies with prepaid plans for their employees, promoting lifestyle programs.

 Provide service in Out-patient Primary Care in Companies with Colmedica´s prepaid medical agreements. Making an accurate diagnosis and appropriate treatment options for them. Keeping properly medical records with high confidentially and continuously updated
 Perform monthly morbidity report of each company assigned and results in prevention programs developed.
 Support Occupational Health Programs regarding specific problems each company.

 Medical consultation and application of non-invasive procedures for health care body and facial aesthetics.

 Provide periodical Occupational health tests.
 Perform occupational examination entrance and output.

 Coordinate the CTC development at national level for the authorization of high cost procedures to military personnel and members in the health subsystem.
 Provide support and issuing recommendations to health network services to further development and coverage the population in accordance of health statistics.
 Medical and Technical supervision to agreements with the external network and the Central Military Hospital.
 Support of the development and Execution of the medical authorization process at the Central Military Hospital.

 Provide basic medical assistance, emergency care, Out-patient services, and Emergency second level and in patient service second level.
 Aeromedical Evacuation in accordance patient condition.
 Participate in health brigades.
 Perform health prevention programs and promote them to the population assigned.