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Kathy Cross CV

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					               Kathleen A. Cross, R.N., B.S., M.S.C.C.
                         866 Hillview Circle • Simi Valley, CA 93065 • (805) 577-7851
                                           kcross@deciphermed.com

                                     AREAS OF EXPERTISE

Nurse Consultant                         Managed Care
Hospital/Medical Bill Audit              Utilization & Quality Management
Case Management                          Home Health & Hospice
Medicare Set-Aside Allocation            Worker’s Compensation Cost Containment

                                  EDUCATION & LICENSURE

    •   B.S., Health Science, 1983, Chapman University, Orange, California
    •   Nursing Diploma, 1976, Seneca College School of Nursing, Toronto, Ontario, Canada
    •   California R.N. License, #330189
    •   International Commission on Health Care, Medicare Set-Aside Consultant Certification
        Number 0658

                               PROFESSIONAL EXPERIENCE

NURSE CONSULTANT, 7/97-Present
  Legal Nurse Consultant:
    • Evaluate, analyze, and render informed nursing opinions on the delivery of health care and
        resulting outcomes.
    • Offer support on medical related litigation in the following areas: Personal Injury, Product
        Liability, Medical Malpractice, and Worker’s Compensation.
    • Review, decipher, and summarize medical records, prepare chronologies, and timelines.

 Business Development:
   • Designed medical record templates, review process, and policies and procedures for medical
       record abstraction software for claims processing in the insurance industry.
   • Trained physicians employed by a Business Product Offshore (BPO) to medically abstract and
       analyze all types of medical records using the software system.
   • Provided international consulting services for ongoing education and training of the BPO.

Hospital/Medical Bill Auditing:
   • Review hospital/medical provider bills for accuracy of billing and coding.
   • Identify overcharges and opportunities for cost savings for insurance companies, third party
        administrators, self-funded companies, and individual payors.
   • Provide education and training regarding cost-containment procedures.

Worker’s Compensation:
   • Perform utilization review services to assure that the injured or ill worker receives timely and
       appropriate medical care, from an appropriate provider, using evidence based guidelines.
   • Collaborate with physician advisors for appropriate plan of care for the injured or ill worker.

PACIFICARE OF CALIFORNIA, 01/02-3/03
  Medical Management Consultant
   • Perform assessments of medical group, IPA and hospital health care delivery systems.
   • Provides consultant services to medical groups, IPA and PacifiCare Concurrent Review Nurses.
   • Provides training and education regarding health care delivery, cost containment, medical record
       review, and hospice care.
PROFESSIONAL HOME HEALTH SERVICES, Thousand Oaks, CA, 6/98-3/01
  Senior Account Manager
    •    Marketing and sales of home health and home infusion services.
    • Contracted with Managed Care Organizations, Medical Groups and private physicians.
    • Presentation of outcome reports, proposals, and educational seminars to clients.

FAMILY HEALTH CARE MEDICAL GROUP, INC., Simi Valley, CA, 3/93- 6/98
  Director of Case Management, for medical group/IPA with 65,000 managed care members. 1/97- 6/98
    • Outpatient referral process. Revision of utilization review process to increase cost containment.
    • Inpatient case management, including on-site review and discharge planning.
    • Catastrophic high- risk case management.
    • Education of staff and physicians to managed care and cost containment practices.

  Manager, In-Patient Case Management, 1/96- 1/97
  Quality Management Specialist, 3/93- 1/96

PACIFICARE OF CALIFORNIA, Cypress, CA, 10/91- 3/93
  Utilization Management Specialist for major statewide health maintenance organization (HMO).
    • Oversight of medical group utilization management programs. This included training of staff and
         physicians on cost containment procedures.
    • Audited on-site medical records; monitored quality of care.
    • Analyzed utilization reports and related data to determine areas of potential cost containment.
    • Prepared and presented cost analysis reports to medical directors and senior management.
    • Conducted pre-contractual medical group quality evaluations.
    • Evaluated and critiqued utilization review / quality management meetings and programs.

GREATER VALLEY MEDICAL GROUP, Northridge, CA, 10/90- 9/91
Manager of Utilization Review, Quality Assurance; Director of Nursing
   • Case management and discharge planning; quality management program.
   • Managed 18-20 licensed nurses and medical assistants at multiple office sites.

BLUE CROSS OF CALIFORNIA, Woodland Hills, CA, 2/88 -9/90
Supervisor Utilization Review, 8/89- 9/90
   • Supervised / audited daily activities of major review center including 22 RNs and utilization staff
        performing preadmission, concurrent, and retrospective review of health care services.
   • Prepared / managed an annual department budget.
   • Developed policies and procedures.
   • Supervised / audited outside review organizations and hospitals.
   • Monitored physician advisor network for compliance to clinical policy.

Utilization Review Coordinator 2/88- 8/89

CLINICAL NURSING POSITIONS IN CALIFORNIA, FLORIDA, & ONTARIO
CANADA 1/77-12/86.

PROFESSIONAL ORGANIZATIONS:

    •   American Association of Legal Nurse Consultants (AALNC)
    •   American Association of Medical Audit Specialists (AAMAS)
    •   National Alliance of Medicare Set-Aside Professionals (NAMSAP)

				
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