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Jessica Claire
  • Montgomery Street, San Francisco, CA 94105 609 Johnson Ave., 49204, Tulsa, OK
  • Home: (555) 432-1000
  • Cell:
  • resumesample@example.com
Professional Summary

Over 24 years of work experience with increasing levels of responsibility. Driven and compassionate Fraud Control and Privacy & Security Officer, capable of handling a wide range of compliance functions. Oversight of three distinct programs, Privacy & Security, Fraud, Waste & Abuse and Compliance Training program. Extensive experience investigating allegations of wrongdoing and privacy and security breaches, including implementing (or overseeing the implementation of) corrective actions to resolve substantiated findings. Expert in coordinating, implementing and managing training and educating the workforce on compliance related matters to include fraud, waste and abuse detection and prevention and privacy and security awareness and obligations.

Professional Experience
Fraud Control and Privacy & Security Officer (Manager) (2010 - present) , to
Kaiser PermanenteCity, STATE,

Implements region-wide privacy and security compliance initiatives to ensure the execution of corporate compliance directives in the region


Develops, maintains, and directs the region’s Privacy and Security Compliance program, to include development of applicable policies and procedures, training, communication, auditing, and monitoring, and investigation of privacy and security complaints


Develops, recommends, and implements the region's Fraud, Waste and Abuse prevention initiatives, to include developing and initiating the annual FWA survey, to analysis of findings, reporting findings to senior management, and auditing for ongoing compliance with corrective action plans


Oversees or conducts – either as the lead investigator or in partnership with others – investigations into allegations of wrongdoing committed by vendors, employees, members, and providers; and, allegations of privacy and security issues


Oversees the annual compliance training programs for the health plan and specialty training for both the health plan and the medical group, to include overseeing training module launch implementation of instructor-led, web-based, and one-on-one instruction; developing status reports for delivery to senior management, and developing corrective action plans to address non-compliance


Manages and develops staff within the department. Coaches staff on individual development opportunities

Program Manager, Fraud, Waste & Abuse (2007 - 2010), to
Kaiser PermanenteCity, STATE,

Conducted independent or joint investigations of fraudulent or illegal activities to include recommending and overseeing installation of covert video surveillance and still photography equipment, reviewing captured documentation of subjects and maClaire recommendations on next steps to the Situation Management Team, local stakeholders and the National Special Investigative Unit


Reported substantiated fraud allegations to the National Association of Insurance Commissioners (NAIC)


Oversight of the investigations of claims fraud cases identified through National Fraud Control Office

Operations Assistant (2005-2007), to
Kaiser PermanenteCity, STATE,

Use supervisory skills to respond to and resolve member problems, concerns, and requests for information


Oversee and manage facility operations: to include housekeeping, security, maintenance, and crisis management


Provide supervision to staff to ensure policy and procedures are maintained


Partner with MCA to coordinate community outreach programs including school partnerships, open houses, volunteer program etc


Review and finalize facility proposals for community outreach programs


Serve as liaison between the call center, member services and other departments as appropriate


Deliver training and coaching to medical office employees, i.e. orientation, system implementation, product knowledge


Coordinate/assist the project manager with remodels moves, including communicating with other departments


Maintain monthly department budget reports


Facilitate team meetings


Ensure designated areas are in compliance with regulatory guidelines and is prepared for surveys and audits


Coordinate safety and emergency procedures per organizational and regulatory standards

Certifications

Member of Healthcare Compliance Association - Certified Healthcare Privacy Compliance (CHPC)


Member of Association of Certified Fraud Examiners - Certified Fraud Examiner (CFE)

Education
MBA: Business Administration concentration Security Management, Expected in 2010
Keller Graduate School of Management - Decatur, GA
GPA:
Bachelor of Science: Business Administration concentration Project Management , Expected in 2007
DeVry University - Decatur, GA
GPA:
Skills

HIPAA

Investigations

Training Awareness

Leadership and collaboration

Analytical

Relationship building

Interpersonal

Oral and written communication

Time management

Ability to work and lead with little direction

Lead and direct others



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Resume Overview

School Attended

  • Keller Graduate School of Management
  • DeVry University

Job Titles Held:

  • Fraud Control and Privacy & Security Officer (Manager) (2010 - present)
  • Program Manager, Fraud, Waste & Abuse (2007 - 2010)
  • Operations Assistant (2005-2007)

Degrees

  • MBA
  • Bachelor of Science

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