Sophia Pagan

I am a regulatory compliance and grievances specialist with over five years supporting Medicare and Medi‑Cal environments. I focus on case audits, policy interpretation, and producing compliant written determinations that support audit readiness.

I conduct detailed investigations using claims history, medical records, provider documentation, and EHR data to evaluate original determinations and identify risk trends. I ensure 100% adherence to CMS and DHCS timelines, documentation standards, and requirements.

I have managed and resolved 60–70 regulated grievance and appeal cases monthly and maintained a 98% on‑time closure rate. I collaborate cross‑functionally with claims, billing, clinical, and compliance teams to deliver policy‑aligned resolutions.

I prepare detailed case summaries and supporting documentation for audits and regulatory inquiries, and I bring a disciplined, deadline‑driven approach to mitigating recurring compliance issues.