Curriculum Vitae of Pauline Sanders, RN, MBA, PHN, CPHRM, LNCC

:

Legal Nurse Consultant Certification (LNCC), California.

:

Healthcare Mediation Training, California.

:

Registered Nurse, Active License, California.

:

Registered Nurse, Active License, Mississippi.

:

Certified Professional in Healthcare Risk Management (CPHRM).

:

Coronary Care Certification.

2004:

Claims Coding.

2003:

Legal Nurse Consultant Certificate Program California State University at Hayward. ABA approved program. Completed an Internship with Law Office of Bohn & Bohn, San Jose, CA.

1999:

Medicare Compliance Specialist Certification California State University at Hayward.

:

Public Health Nurse Certification.

1996:

Train the Trainer Certification, University of Phoenix.

1981 - 1996:

CPR Instructor (Basic Cardiac Life Support).

:

CPR-current (Basic Cardiac Life Support Provider).

:

Advanced Life Support Provider-current (ACLS).

1994:

Masters of Business Administration, University of Phoenix, G.P.A. 3.5.

1984:

Bachelor of Science, Health Services Administration, St Mary's College, CA, G.P.A. 3.7. Designed, coordinated, and evaluated an eight-month project on Stroke Support Group services for a retirement facility.

1974:

Associate Degree in Nursing, Northeast Mississippi Junior College, MS.

2009 - Now:

Executive Director.
Synergy Homecare Eastbay.

2007 - 2009:

Director of Risk/Patient Safety.
Kaiser Foundation Hospitals.

2005 - 2007:

Risk/Patient Safety Coordinator.
Kaiser Foundation Hospitals.

2005 - Now:

Risk Management.
Kaiser Foundation Health Plan, Santa Clara, CA.

2004 - 2005:

Case Manager & Discharge Planner.
Kaiser Foundation Health Plan, Oakland, CA.

2001 - 2004:

Managed Audits, Compliance, Quality, and Training for Claims Administration.
Kaiser Foundation Health Plan, Oakland, CA.

Had oversight for the operations of audits, quality, compliance, and training unit. Responsible for monitoring cost containment and quality standards. Constantly involved with root cause analysis, risk identification, internal/external surveys. Responded to compliance issues through reports and negotiated corrective action plans. Responsible for department staff training on corporate compliance and HIPAA compliance. Developed and manages Continuous Quality Improvement Committee for Northern California Claims.

1999 - 2004:

Registered Nurse Medical/Surgical Unit.
Stat Nursing Agency, San Francisco, CA.

2000 - 2001:

Senior Internal Compliance Auditor.
Kaiser Foundation Health Plan, Oakland, CA.

Performed regulatory audits across the program to furnish analysis, recommendations, and to identify best practices concerning activities reviewed. Wrote detailed audit reports for submission to senior leadership. Claims, appeals, and organization determination audits for mock HCFA (Health Care Finance Administration), NCQA (National Committee on Quality Assurance), and DMHC (Department of Managed Health Care for California) compliance. Claims, appeals, and organization determination audits to analyze timeliness, payment accuracy, and appropriate denials of services. Internal Credentials audits for MDQR (Medical Directors Quality Review) involved Practitioners and Providers licensure & certifications.

1999 - 2000:

Clinical Review Supervisor.
Kaiser Foundation Health Plan, Oakland, CA.

1997 - 1999:

Medicare and Health Plan Expedited Appeals Case Manager.
Kaiser Foundation Health Plan, Oakland, CA.

Concurrently reviewed and prepared members appeals for denial of health care services. Preparation involved investigating and obtaining information from all health care providers who may be associated with case or contacting providers with expertise in the respective illness. Reviewed and analyzed medical records to determine if member required acute care versus non-acute care while maintaining advocacy for quality care to the member. Cases presented daily to medical directors for reconsideration.

Prepared and presented chronologies of medical cases to Mini Appeals and Regional Appeals Committees for payment reconsideration. Maintained and enhanced all communications with executive level medical staff and departments employing Medicare, HCFA, CHDR (Center for Health Dispute Resolution), and DMHC regulations intermittently. Supervised and trained staff in expedited appeals and regional case management; coordinated outside member service issues involving other regions and the central office.

1991 - 1997:

Quality Assurance-Utilization Management Coordinator.
Kaiser Foundation Hospital, Hayward, CA.

Evaluated acute care versus non-acute care needs during the member's hospitalization. Facilitated transfers to non-acute services such as skilled nursing facilities, home health care, and outpatient clinic management. Reviewed and analyzed medical records. Developed management reports and served as a member on various hospital committees for patient services utilization. Reviewed and maintained quality of patient care for cost effectiveness. Monitored patient utilization to ensure optimal use of resources while maintaining advocacy for quality treatment. Participated in the JCAHO (Joint Commission on Accreditation of Health Care Organizations) surveys and the NCQA surveys. Relieved department supervisors as needed.

1989 - 1991:

Telephonic Medical Advice Nurse.
Kaiser, The Permanente Medical Group, Oakland, CA.

Provided telephone advice to members using established nursing care advisory criteria. Ensured that nurse standards of care were followed as outlined in the Nurse Practice Act.

1988 - 1989:

Quality Assurance Coordinator.
Oakland Hospital, Oakland, CA.

Designed, implemented, and coordinated Management Analysis Quality Assurance Program.

Trained medical staff, department managers, and hospital staff on Quality Assurance and Risk Management. Participated in JCAHO (Joint Commission on Accreditation of Health Care Organizations) surveys and the CMA (California Medical Association) surveys.

1986 - 1988:

Quality Assurance Analyst.
Washington Hospital, Fremont, CA.

Reviewed necessity for medical admissions. Medical record review and analysis for quality of care issues in the critical care unit, medical-surgical units, obstetrics/gynecology, and the emergency department. Developed medical management screenings, risk management chart studies, and monthly reports to 11 medical staff committees. Selected model case studies to discuss for quality and risks concerns.

1980 - 1986:

Charge Nurse, Coronary Care Nurse.
Eden Medical Center, Castro Valley, CA.

1979 - 1980:

Registered Nurse.
Eden Medical Center, Castro Valley, CA.

1975 - 1978:

Charge Nurse, Registered Nurse - OB/Gyn Unit; Surgical Unit.
Mississippi Baptist Medical Center, Jackson, MS.

1974 - 1975:

Registered Nurse-OB/Gyn, Labor & Delivery, Newborn Nursery.
North Mississippi Medical Center, Tupelo, MS.