Kathleen A. Cross, R.N., B.S., M.S.C.C.
866 Hillview Circle • Simi Valley, CA 93065 • (805) 577-7851
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
NURSE CONSULTANT, 7/97-Present
Legal Nurse Consultant:
• Evaluate, analyze, and render informed nursing opinions on the delivery of health care and
• 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.
• 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.
• 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
• American Association of Legal Nurse Consultants (AALNC)
• American Association of Medical Audit Specialists (AAMAS)
• National Alliance of Medicare Set-Aside Professionals (NAMSAP)