Carlo de Borja - Compliance Strategies

How does he contribute to the team?

Carlo contributes to Compliance Strategies by applying his background as a registered nurse and trained physician with almost two decades of experience in the medical field. With seven years of experience in utilization management, he demonstrates expertise in navigating healthcare delivery, actively participating in universe validation audits, grievance reviews, organization determination audits, and quality improvement initiatives. His work extends to process and workflow improvements, universe improvements, and developing CMS-compliant policies and procedures.

When do we call on him?

Utilization Management
Grievance and Appeals
Clinical Guidelines Consultation
Credentialing

What’s his story?

Carlo joined Compliance Strategies in 2018, bringing a strong foundation in clinical practice and utilization management. His expertise includes direct involvement in prior authorization and appeal case reviews, where he applies his medical knowledge and deep understanding of clinical criteria guidelines to ensure accurate and compliant case resolutions.

Committed to regulatory compliance, Carlo has participated in CMS and NCQA UM operational audits, demonstrating a thorough understanding of industry regulations. His experience in CMS mock audits with multiple clients nationwide has given him unique insights into identifying gaps, implementing corrective actions, and supporting health plans in optimizing their operations while maintaining regulatory compliance. His dedication to maintaining high healthcare standards continues to drive his efforts in helping organizations navigate complex regulatory requirements effectively.