Summary of Qualifications

Results orientated professional with unique background as regulatory health care

compliance analyst for major health care regulatory department as well as many
years as consultant, quality improvement program management, and clinical admini
strator. Global experience of national healthcare market having managed utilizat
ion review, case management programs, and monitoring of licensed managed health
care plans. Strengths include planning, organization, problem solving and strate
gic planning.
Professional Experience
La Vida Medical Group & IPA, Los Angeles, Ca
Quality Management/Compliance Specialist
May 2008-present
Responsible for day to day operational activities of the QM Department and quali
ty improvement functions of the Medical Group contracted with fifteen health pla
ns.
Tracked appeals and grievance backlogged four months by provider and type and de
veloped corrective action plans in coordination with the Medical Director and QM
chairman.
Responsible for oversight of the Credentialing and Recredentialing providers in
coordination with the Credentialing Department, consumer medial claim grievances
and appeals, facility medical group surveys, and compliance with state, federal
, and NCQA standards.
Liaison and communication link between network managers, claims department, Util
ization Management, clinical managers and Corporate Administration.
Identify problem areas for policy, consultative advice, and corrective action pl
ans to the medical group.
Department of Managed Health Care. Los Angeles, Ca
Staff Health Care Service Plan Analyst April 2005-March 2008
(Promoted from Associate Health Care Service Analyst)
Associate Health Care Service Analyst May 2001-April 2005
Special Consultant January 2001- May 2001
Seven years of increased responsibilities performing plan management and lead co
mplex medical regulatory
Audits for regulatory compliance of 41 licensed full service and specialized (be
havioral health, vision, dental,
chiropractic) managed health care delivery systems and joint medical managed car
e plans, enrollment ranged from 250,000 to 6 million enrollees.
Facilitated and coordinated multidisciplinary teams consisting of interdepartmen
tal staff, counsels, financial examiners, and consultants in meeting all survey
project benchmarks. Served as in house consultant for sensitive program issues.
Planned, organized, and directed efforts of team members, medical consultants, a
nd interdepartmental staff members in preparation of survey activities and techn
ical reports.
Evaluated health maintenance plan systems, processes, and data trends for non co
mpliant regulatory activity and established corrective action plans and recommen
dations with referrals to enforcement as needed.
Investigated and monitored consumer complaint calls and claim activity referrals
from health maintenance organization help center in collaboration with departme
nt attorneys in licensing division.
Professional liaison between staff of health maintenance organization health pla
ns, consultants, and department during undertakings and enforcement processes. P
articipated in analyzing and evaluation of regulations, standards, and e-Filings
.
Collaborated with department enforcement division counsels in constructing memor
andum for enforcement actions of health plans with repeated non compliance of re
gulatory deficiencies, outcome 3 million dollar fine.
Adapted theoretical and practical experience of policy analysis, program evaluat
ion, political systems, and strategic planning from doctoral program in public a
dministration to evaluate public policy and apply to departments compliance deve
lopment process needs.

Ronnie Cooper Medical Inc, Los Angeles, Ca March 1998 to January 2001
Managed Care Specialist
Utilization Management supervision for licensed health care organization respon
sible for coordination of transition of health care services of 1 million membe
rs during merger between two managed health care organizations and 77 medical i
ndependent physician associations, outcome 90% enrollee accommodation.
Negotiated health care service rates. Facilitated contract negotiation and lette
r of agreement for enrollees within 77 independent associations contacted with p
rimary managed health care plans.
Evaluated and audited managed health plan administrative end data and medical re
cords for 1999 HEDIS project to ensure regulatory compliance with reformations.
Sample size 5612 members.
Investigated, analyzed, and monitored work primary and repeated injury claims.
Participated in the
adjudication of claims process with the Workers Compensation Appeals Board in
California.
Grace Jimenez-Hennessy Managed Care Consultant January 1995 to January 2005
Quality Management Consultant
Commissioned with task to conduct entire HEDIS survey at medical group level, di
rected and organized staff in collecting 500 data files and review of documentat
ion of quality management activities to ensure physician provider organizations
compliance against national committee of quality assurance standards of accredi
tation
.Created quality management reports and presented to utilization and quality ma
nagement committees including customer service and provider satisfaction data to
identify systematic problems, track and trend consumer complaints , gathered ag
gregated data and conducted barrier analysis with 20% improvement in committee r
ecommendations with implementation and follow up by medical director and plan
board of directors.
Oversaw the quality management program, utilization review program, medical mana
gement, and physician relations and physician credentialing independent physicia
n associations with commercial and health organizational maintenance products. P
repared and implemented the quality improvement program description, annual work
plan and evaluation to identify areas for improvement to ensure quality managem
ent efficiency.
California Medical Audit July 1991 to March 1998
Managed Care Consultant
Conducted utilization management review and evaluation of Medical tars on daily
basis for intensity of services and severity of care at St. Vincents Medical Cen
ter with an 8.5 % increase in reimbursement.
Tracked, adjudicated, and adjusted claims for managed care health plans and cont
racted medical groups for durable medical equipment and health services with a 3
0% reduction.
Evaluated and measured effectiveness of medical care intervention and conformanc
e to plan guidelines.
Evaluated program operations, process and strategies to identify managed care pl
an internal controls to ensure regulatory compliance and adherence to contract p
rovisions and letter of agreements.
St. Vincents Surgical Ambulatory Center April 2003 to April 2005
Clinical Administrator
Managed full scope of day to day operations. Hired, implemented disciplinary act
ions, and dismissed staff. Directed and conducted work activities of 15 employee
s and 7 medical physicians with St. Vincents hospital department, physician offi
ces and suppliers.
Eliminated claim backlog since 1987. Created new filing systems, procedures, and
ensured accessibility too important documents.
Turned around 60+ outstanding receivables from 30% to an average of 2%
Identified and consolidated, and implemented a system color coded charts, elimin
ated duplication of records of 7 medical group physician.
Implemented cross training of staff in operating room and recovery room area fun
ctions with a 15% increase in efficiency rate, cost savings, and resolution of s
taff shortage.
Consolidated vendor contracts for surgical instruments, medical supplies, and eq
uipment for cost savings per year. Implemented cost saving procedure and policie
s throughout surgical ambulatory center.
Chaired the Quality Assurance Program, analyzed and conducted studies, and revis
ed policy and procedures in accordance with state and federal regulation and nat
ional committee quality assurance indicators.
Monitored and evaluated surgical documentation for CMS standards compliance.
FHP Health Plan September 1990 to September 1991
Acute Care Coordinator, Utilization Review
Directed intra and interstate transportation of members averaging 12 per day via
air and ground transportation for follow up care.
Facilitated re entry of member into managed health care system from external hos
pital facilities through the arrangement of Plans specialists to include and tre
at members after stabilization.
Oversaw and monitored patient care obtained form Plan contract and non contracte
d hospitals in Los Angeles County region on a daily basis averaging 30 patients
to ensue positive health care consumer outcomes.
Expedited insurance payment and weekly review and verified length of patient hos
pital stay through chart analysis, auditing, and data collection in collaboratio
n with utilization department.
Kaiser Permanente Hospital Harbor City June 1978 to March 1980
Supervisor, Hospital Relief Supervisor
Handled all administrative duties monitoring in house staffing and outside contr
acting personnel in 231 beds managed care hospital and assisted as relief house
supervisor overseeing intensive care units, telemetry unit, and emergency room.
Executed responsibilities interviewing, directing, training, and disciplining st
aff.
Assisted intermediate supervisor with data collection for budgeting of 2 units f
or fiscal year and participate in annual fiscal budget input for the unit.
Participated in ad hoc committees for purpose of developing policy and procedure
s for resolution of identified problems.
Trained nursing personnel in technical care and instructed CPR certification to
community members with outcome of increased collaboration and alliances with loc
al agencies.
Coordinated and scheduled patient care with academic instructors and student nur
ses from affiliating nursing
AMI, Harley Street Clinic, London, England 1986-1987
Coronary Care Specialist
Brotman Memorial Hospital November 1973 to May 1978
Charge Nurse, multiple intensive units, recovery room,
and emergency room.
Oversaw and coordinated activities four surgical patient wings with 120 beds for
crisis management during
nursing strike.
Directed and delegated patient care responsibility to 6 register nurses and 2 nu
rse aids in four intensive care
units based on continuous improvement in a 250 bed non profit hospital.
Trained new hospital orientees and medical staff to surgical procedures and hosp
ital protocols for quality
improvement.
EDUCATION, LICENSURE:
CORO Health Leadership Program Certificate, CORO Fellow HPL III- CORO Southern C
alifornia
Recipient- selected out of 200 candidates.
DOCTORAL PUBLIC ADMINISTRATION Graduate course work completed except
Dissertation-University of LA VERNE, La Verne
MASTERS OF HEALTH CARE ADMINISTRATION-University of La Verne, La Verne

BACHLOR OF SCIENCE DEGREE in NURSING , Public Health Nurse C certificate -

California State University, Los Angeles
Quality Assurance Utilization Review Certificate-Chatsworth
UNITED.KINGDOM.COUNCIL.NURSING.LICENSED-London, England
CALIFORNIA BOARD REGISTERED NURSE
COMMUNITY EMERGENCY RESPONSE TEAM TRAINING/CERT
BASIC LIFE SUPPORT INSTRUCTOR-Los Angeles

PROFESSIONAL AFFILIATIONS:
Member-American College of Healthcare Executives
American Society of Public Administration
Ca Bar Association/Healthcare Division
California Association of Quality Assurance Professionals
The Health Care Forum (The Association of Western Associations)
Woman Healthcare Administration
American Nursing Association
International Hospital Federation
American Association of Critical Care Nurses