Jessica Claire
Montgomery Street, San Francisco, CA 94105
Home: (555) 432-1000 - Cell: - - -
Management Profile

A high-performing Regulatory and Compliance Manager with expertise in directing complex projects.Successful at developing positive business relationships with industry peers. Recognized for being instrumental and reactive to new regulatory and governance requirements. Highly adept in identifying key gaps or risk exposure while implementing checks and balance systems to support the changing business needs.

Professional Experience
2012 to 2015
Director of Medicaid Compliance Loan Depot Nashville, TN,
  • Lead Medicaid Compliance SME to support Emblem Health business groups Manage compliance staff of x employees and providing them with corrective action guidance and direction
  • Direct all NYSDOH compliance requirements to internal business groups at Emblem Guarantee all business groups implement the compliance requirements through internal audits
  • Successfully completed Article 44/49 and CHPlus audits conducted by New York State Department of Health (NYSDOH)
  • Provide Compliance requirements for BH-HARP implementation and query reports to NYSDO Facilitate monthly strategy meetings to the CEO and Executive team for regulatory and compliance efforts
  • Manage all NYDOSH member and compliance issues across the organization The Principal point of contact for any government investigations
2011 to 2012
Director of Quality Assurance Livanova San Jose, CA,
  • Compliance Officer for the PACE Compliance and Privacy (HIPAA) and provided training to the new hires
  • Strategically developed and implemented the annual QAPI plan for the company, State and Federal agencies
  • Analyzed risk management data and quality assessment improvement performance data to protect company assets
  • Developed, monitored and reported on PACE Health Plan Management Systems quality indicators Implemented and audited compliance, privacy laws and regulation that impact health care systems
07/2005 to 11/2011
Regulatory Affairs Manager State Of Oklahoma Durant, OK,
  • Regulations and Contractual Subject Matter Expert for Medicaid, Family Health Plus, Child Health Plus, and A Plus products impacting over 450,000 member lives
  • Single point of contact for all external/internal regulatory, compliance and contractual affairs
  • Successfully managed Article 44/49 and CHPlus audits conducted by New York State Department of Health (NYSDOH), New York City Department of Health (NYCDOH), the Independent Peer Review Organization (IPRO) which resulted in eliminating large penalties and fines for the company
  • Led the consumer satisfaction and quality improvement efforts for City and State Department of Health (CAHPS, QARR, HEDIS)
  • Facilitated monthly presentations to the CEO and executive team regarding regulatory and compliance efforts
  • Internal Approver for all written materials and programs relating to new and existing consumers Directly supervised regulatory analyst staff for daily operations and managed corrective action plans for specific employees
01/2002 to 10/2002
Compliance Officer State Of Oklahoma Wilburton, OK,
  • Primary resource for compliance issues regarding state regulations and laws, accreditation, filings and licensure
  • Solely responsible for preparation and management of regulatory site visits from City and State agencies
  • Created an internal audit procedures to monitor compliance
  • Analyzed contract requirements and advised multiple site locations on the potential risks to the firm
  • Supervised Compliance related staff which included delivering formal written reviews and employee feedback
  • Established the quarterly health plan newsletter for internal employees nationally
2000 to 2001
  • Primarily responsible for analyzing and monitoring regulations for Medicaid contracting organizations to assure compliance with state and federal laws
  • Implemented new regulations with functional departments, including corporate, regional and local offices
  • Managed program compliance activities for Medicaid in concert with corporate, regulatory and local staff
  • Monitored enrollment, claims, pharmacy, dental, behavioral health and complaints received by state and regulatory audits
  • Developed and issued all marketing documents /member handbooks according to contract specifications Interacted directly with providers for Access and Availability Surveys.
05/1998 to 08/2000
Business Systems Analyst/Project Coordinator Prudential/Aetna US Healthcare City, STATE,
  • Liaison between Prudential and Delegated Provider Organizations (DPO) Implemented new deals and oversight of existing deals for up to 300,000 members
  • Co-wrote the national DPO Oversight Policy and Procedures
  • Manual Lead Facilitator at IT due diligence meetings, mapping sessions, and conference calls
  • Created policies and procedures, reporting structures for Electronic Data Interchange (EDI)
  • Managed the approval process for all vendor mapping specifications for critical data interfaces.
Education and Training
Expected in June 1994
Bachelor of Arts (BA): Communications/Public Relations
City College of New York - , NY

Communications/Public Relations

Skill Highlights
  • MS Excel, Word, PowerPoint,Visio

  • Lotus Notes and Outlook

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Resume Overview

School Attended

  • City College of New York

Job Titles Held:

  • Director of Medicaid Compliance
  • Director of Quality Assurance
  • Regulatory Affairs Manager
  • Compliance Officer
  • Compliance Officer
  • Business Systems Analyst/Project Coordinator


  • Bachelor of Arts (BA)

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