Director Of Quality Assurance & Risk Management Corporate Compliance & Safety Officer resume example with 20+ years of experience

Jessica Claire
Montgomery Street, San Francisco, CA 94105 609 Johnson Ave., 49204, Tulsa, OK
Home: (555) 432-1000 - Cell: - - -
Professional Summary
Sixteen (16) + years of audit/compliance experience in operational/finanClairel/Sarbanes-Oxley Act (SOX 302 & 404)/Medicare & Medi-Cal reimbursement & compliance audits for government contracting, consulting (public accounting), insurance, manufacturing, and healthcare industries. Extensive background in all stages of audits, including: planning, risk assessment, data gathering and analysis, evaluation, testing of controls, reporting, and follow-up. Exceptional knowledge of audit procedures, including planning, techniques, test and sampling methods involved in conducting various types of audits. Proficiency in using Computer Aided Audit Tools (CAATs) such as Audit Command Language (ACL) software. Experience in identifying and evaluating risks during review and analysis of System Development Life Cycle (SDLC), including design, testing/QA, and implementation of systems (e.g. User Acceptance Testing (UAT) review). Experience in testing the End-User Computing (EUC's) tools. Extensive experience in conducting company-wide fraud risk assessment, fraud investigations, and Self-Assessment Surveys. Experience in evaluating various risks, vulnerabilities, threats, outcomes, probability, risk impact, and risk score-all are used in creating a 'HIPAA Entity-Level Risk Assessment' as well as Risk Assessments for systems that house ePHI. Knowledge and use of claims payment principles and coding structures. Familiar with PhysiClairen Practices' Billing and Coding procedures/processes, including: claims "scrubbing"/submission and AR & denials management. Familiar with the JCAHO's (Joint Commission on Accreditation of Healthcare Organizations) Hospitals & Ambulatory Care Standards and JCAHO's Survey process. Thorough knowledge of Medi-Cal Documentation Standards related to mental health records. Thorough knowledge and implementation of OIG's 7 Elements of a Compliance Program. Extensive experience in assessing risks and monitoring/resolving of issues in these following areas: Accreditation and Clinical Compliance, Infection Prevention and Control, Patient Relations, Quality Measurement, Performance Improvement, and Clinical Risk Management and Patient Safety. Familiar with the Lean / Six Sigma Process Improvement Models; JCAHO's Quality Measures Reporting/National Patient Safety Goals; Reporing of Hospital Quality Indicators/Measures/Outcomes; Patient Satisfaction Measures (HCAHPS' Survey); JCAHO's Hospitals and Behavioral Health Organizations' Standards. Working knowledge of the HIPAA Privacy & Security Rules.
Education and Training
Expected in 2003
Master of Business Administration: Health Care Management
University of Phoenix - Pasadena, California
Health Care Management
Expected in 1999
Bachelor's: Accounting Economics
California State University Northridge - Northridge, California
Accounting Economics
Expected in 02/04/2013
Claire (Certified Internal Auditor) Lic.No.: 81725; Certified: 01/12/2009 CRMA (Certification in Risk Management Assurance):
- ,
Skill Highlights
  • Guest services
  • Inventory control procedures
  • Merchandising expertise
  • Loss prevention
  • Cash register operations
  • Product promotions
Professional Experience
06/2016 to Current
Director of Quality Assurance & Risk Management / Corporate Compliance & Safety Officer American Modern Insurance Group Lake Charles, LA,
  • Responsible for the strategy, design and administration of the agency's Quality Assurance and Risk Management functional areas, with a specific emphasis on Medi-Cal [mental health] records.
  • Responsible for identifying and measuring adverse events and/or the potential for an adverse event, designing and implementing a plan to avoid risk(s) and/or minimize damage and loss.
  • Provided leadership, regulatory and quality compliance, and direction for projects and process improvement that effectuate client care and relations, performance improvement and quality.
  • Developed and implemented plans and processes to prevent breaches of privacy.
  • Developed a HIPAA Breach Risk Assessment Tool.
  • Created Corporate Ethics/Compliance Hotline.
  • Investigated, followed up, and reported the results to the CEO and the Board of Directors.
  • Responsible for creating and maintaining compliance policies and procedures.
  • Served as Agency's Corporate Compliance Officer/HIPAA Privacy Officer and the Chair of the Compliance Committee.
  • Conducted Internal Audit Reviews and Internal Investigations.
  • Communicated the results to the Senior Executive Management.
  • Conduct regularly scheduled Facility Safety Inspections.
  • In charge of investigating any issues/situations resulting in hazardous or unsafe working conditions.
  • Monitor for compliance with the Agency's Injury & Illness Prevention Program.
  • Chair of the Safety Committee.
  • Participated in writing/review of the relevant information regarding the Counties' Requests for Proposals projects/bids to extend/obtain the contracts.
  • Developed and implemented: an annual Compliance Work Plan, quarterly Compliance Program [Employee] Survey, and an annual Compliance Risk Assessment.
  • Created and modified policies (e.g.
  • HIPAA Privacy/HIPAA Security Policies Manuals), including separate: Compliance Plan and Compliance P&Ps.
  • Oversaw and monitored the process and the required documentation whenever copies of clients' Medical Records had been requested.
  • Together with the company's Legal Counsel, reviewed and processed subpoena requests for the releases of clients' Medical Records.
  • Directed/Supervised a staff of five (5): Compliance Analysts and QA SpeClairelists who were focused on compliance/QA-related functions/activities to support SCCS' overall compliance & QA structure/efforts.
09/2016 to 06/2016
Senior Internal Auditor American Modern Insurance Group Lancaster, PA,
  • Responsible for conducting various operational/compliance/clinical/IT-related system-wide audits (for MHS as a whole) as well as audits for each of the six (6) company's hospitals: Long Beach Memorial Medical Center, Community Hospital of Long Beach, Miller Children's Hospital, Orange Coast Memorial Medical Center, and Saddleback Memorial Medical Center (two locations: Laguna Hills & San Clemente).
  • Audits included: Property & Equipment Leases, IT Security & Access Controls, Adult & Pediatric Sleep Centers, Emergency Department, Observation Unit, Clinical Research, Outpatient Rehab Clinics, Vendor Contracts/Business AssoClairete Agreements, Medicare PhysiClairen Supervision Compliance, Medicare Overpayments, Outpatient Pharmacy Billing, Medi-Cal Proof of Eligibility, Units-of-Service (UOS) Reporting, Pharmacy 340B, Chart Deficiencies, DME Billing, PhysiClairens Contracts, Core Measures & Quality Measures Reporting, and Intensive Assessment Committee's Performance & Monitoring, Case Management & Discharge Planning, Medical Staff Offices Audit, BenefiClairery Designation Audit, and Charge Capture Audit.
02/2016 to 08/2016
Senior Internal Auditor/Auditor-In-Charge Kaiser Permanente City, STATE,
  • Performed/conducted process walkthroughs and documented business systems/processes using narratives and flowcharting techniques.
  • Prepared and utilized risk assessment tools, audit-related exhibits, working papers, audit programs, and various required audit communications.
  • Developed the following risk assessment tool: the BRAT (Business Risk Assessment Tool).
  • Analyzed findings, determined root causes, formulated opinions, and developed recommendations.
  • Performed detailed analyses of the various data (e.g.
  • medical claim transactions and employees' timecard/access badge time details) using ACL program.
  • Lead various operational/finanClairel/compliance/SOX audits, determined and identified potential risks and opportunities to the organization, and developed appropriate corrective action plans.
  • Conducted audits/speClairel investigations in coordination with other Kaiser's audit teams & conducted assigned audit projects independently and/or with team members.
  • Directed/Supervised a staff of three/four (3/4): Auditors I's and II's who conducted various operational/finanClairel/SOX audits.
05/2016 to 02/2016
Senior Internal Auditor / CONTRACTOR Unified Western Grocers, Inc City, STATE,
  • Planned, coordinated, and performed various operational audit reviews including the following: Promotional Accounting, Layered Inventory, Bakery/Dairy Manufacturing, and Warehouse Inventory Management/Distribution.
  • Prepared various flowcharts and transaction walkthroughs of the targeted audit processes.
  • Administered and performed employees' interviews based on the responses to quarterly Self-Assessment Survey.
  • Developed audit programs and prepared audit reports in order to communicate significant audit issues to senior management.
  • Monitored process owners' responses to prior year audits in the Follow-Up of Management Actions database.
  • Consulted with various levels of management to determine proper remediation efforts.
04/2016 to 04/2016
Senior Internal Auditor 21st Century Insurance, Inc City, STATE,
  • Planned, coordinated, and performed various operational audit reviews for the following company's departments: Accounts Payable, Purchasing, Human Resources, Claims, Corporate Legal, Premiums, and Customer Care.
  • Developed risk and control matrices, audit programs, and prepared audit reports / memos in order to communicate significant issues to senior management.
  • Reviewed assigned staff auditors' work papers and issued review notes.
  • Performed detailed analyses of the various finanClairel data (e.g.
  • AP paid checks, wire transfers, P-card transactions, etc) using ACL program.
  • Performed company-wide anti-fraud risk assessment and analysis.
  • Led company's fraud investigations by conducting and preparing the Summary Investigation Memos.
  • Maintained files, logs, and performed investigative procedures in compliance with company's Employee Ethics & Compliance Hotline procedures.
  • Performed SOX 404 compliance testing of the business cycles' key control activities including process walkthroughs and corroborative inquiries on a periodic basis.
  • Reported all SOX 404 audit findings and work performed into the internal audit repository (PolicyIQ).
  • Directed/Supervised a staff of two (2): Staff Auditors who conducted various operational/finanClairel/SOX audits.
02/2016 to 04/2016
Business Risk Services Auditor Ernst & Young, LLP City, STATE,
  • Performed risk assessment criteria matrices for SOX 404 clients: Health Net, Countrywide, Ryland, and Amgen.
  • Identified key risks and tested the controls.
  • Performed walkthroughs, wrote narratives, and drew process-flow diagrams.
  • Developed customized business processes to identify key performance indicators and critical success factors.
  • Documented clients' business goals, objectives and strategies.
  • Co-developed clients' expectations and communicated audit test results.
  • Designed lead test sheets and tested key process attributes.
  • Performed process-owner interviews.
01/1 to 01/2016
Medicare Auditor III/Senior Medicare Auditor United Government Services, LLC Well Point, Inc City, STATE,
  • Responsible for performing team and independent audits of different healthcare providers (e.g.
  • hospitals, SNFs, HHAs, and home offices).
  • Performed various levels of audit review (e.g.
  • desk review, focus review, field audit review, reopening, appeals, and wage-index review).
  • Handled complex Medicare accounting/reimbursement issues.
  • Utilized CMS (HCFA) Pub 15-1 (Medicare Provider Reimbursement Manual), Pub 15-2 (Cost Reporting Instructions) and PRRB (Provider Reimbursement Review Board) appeal decisions.
  • Held an Audit Team Leader position while auditing large providers: Loma Linda University Medical Center, Cedars-Sinai Medical Center, and Northridge Medical Center.
  • Maintained productive working relationships with providers.
  • Independently conducted Entrance, Pre-Exit, and Exit conferences.
  • Entrusted with confidential data.
  • Directed/Supervised a staff of three/four (3/4): Medicare Auditors I's and Medicare Auditors II's who conducted various Medicare-related/hospitals' cost reports audits.
Professional Affiliations
The Institute of Internal Auditors (IIA): IIA San Gabriel Valley/ Orange County Chapters The Health Care Compliance AssoClairetion (HCCA)
2016 HCCA Compliance Institute National Conference - 20th Anniversary" (April 2016) by the HCCA. Behavioral Health Care Standards - Conference" (October 2015) by the Joint Commission (Chicago, IL). Laws & Ethics in Clinical Supervision" (August 2012) by County of Orange Health Care Agency / Behavioral Health Services (required training for LCSWs, MFTs, and LPs). LEAN Leader Training" (June 2010) by MemorialCare and Joan Wellman & AssoClairetes. Business Writing Skills for Professionals" (March 2009) by Skill Path. Enhanced Communication Skills for Auditors" (November 2008) by The Institute of Internal Auditors. Audit Report Writing" (October 2007) by The Institute of Internal Auditors. Leadership Skills for Auditors" (January 2006) by The Institute of Internal Auditors. Interview and Interrogation Techniques" (September 2005) by Wicklander-Zulawski.
Fluent in written and spoken Russian.
Windows 10/8/7/Vista/XP/2000/98/95, MS Word, Excel, Access, Outlook, Lotus Notes. PowerPoint, ACL v.9.1, Visio 2003. Electronic audit workpapers software programs: AWS and AutoAudit. SOX-related software programs: PolicyIQ and Risk Navigator. Hospital-related patient billing/patient health information programs: EPIC, Keane. Mental health-related EHR system: Claim Trak Counties' billing systems: SIMON, IRIS SAP Crystal Reports 2011. Medicare-related audit software program/CMS Mainframe: KPMG First Audit Tool & Common Working File (CWF). Federal Regulations database: MediRegs. MBA Thesis: "Hospital's Strategic Management Plan" was highly recognized by the panel of instructors as an outstanding work.

By clicking Customize This Resume, you agree to our Terms of Use and Privacy Policy

Your data is safe with us

Any information uploaded, such as a resume, or input by the user is owned solely by the user, not LiveCareer. For further information, please visit our Terms of Use.

Resume Overview

School Attended

  • University of Phoenix
  • California State University Northridge

Job Titles Held:

  • Director of Quality Assurance & Risk Management / Corporate Compliance & Safety Officer
  • Senior Internal Auditor
  • Senior Internal Auditor/Auditor-In-Charge
  • Senior Internal Auditor / CONTRACTOR
  • Senior Internal Auditor
  • Business Risk Services Auditor
  • Medicare Auditor III/Senior Medicare Auditor


  • Master of Business Administration
  • Bachelor's
  • Claire (Certified Internal Auditor) Lic.No.: 81725; Certified: 01/12/2009 CRMA (Certification in Risk Management Assurance)

By clicking Customize This Resume, you agree to our Terms of Use and Privacy Policy

*As seen in:As seen in: