Quality Management Nurse with 15+ Years Compliance Expertise

Mary V. Friscia

***********@*****.***• 818-***-****

Northridge, CA.

http://www.linkedin.com/in/maryfriscia

Healthcare Quality Management Regulatory Compliance Specialist

Leading cross-functional teams in delivery of evidence-based patient-centered care, quality and performance improvement initiatives, risk management, audits, and regulatory/standards compliance

High-achieving quality/utilization review nurse specialist with extensive experience driving results for health plans and healthcare organizations. Proven track record of improving quality, regulatory/accreditation standards compliance, patient safety, and evidence-based patient-centered care. Adept at streamlining processes for better workflow and employee engagement, while also enhancing the patient experience. Talent for training and forging and fostering strong internal and external stakeholder relationships. Well-versed in regulations, standards, and processes for DMHC, NCQA, HEDIS, CMS, The Joint Commission (TJC) Core Measures, EMTALA, and the HCAHPS Survey. Hands-on manager, who will take time to coach and mentor team members for career growth and optimal performance.

Areas of Expertise

Quality & Utilization Management

Clinical Data Abstracts & Medical Correlation

Process Methodologies PDCA & PDSA Processes

Clinical Work Plans Evaluations & Corrective Action Plans

Regulatory/Standards Compliance

Accreditation Surveys/Facility Site Audits

Project Management

Case Management/Discharge Planning

Performance Improvement Initiatives

Quantitative & Qualitative Analysis

Statistical Process Control Chart

Strategic Planning & Execution

Risk Mitigation

DMHC Grievance/Appeals Reviews

High-Impact Presentations

Staff Development & Leadership

Meeting Facilitation Cross Functional

DMHC/NCQA/HEDIS/CMS/TJC

Career Experience

Southern California Medical Center, INC, (FQHC) Corporate Offices, Van Nuys, CA. - November 2021 – July 2022

Quality Improvement Coordinator

Providing the highest quality health care to underserved populations with a focus on education and prevention.

Investigated and responded to Physician Provider and Member Grievance and Appeals, Performed Medical Facility Site Audits, Interfacing with providers & patients in an effort to resolve their concerns. Performed medical case quality reviews to ensure utilization of evidence-based best practices to identify opportunities to improve patient care for all five satellite facilities, Data Aggregation, compiled reports for senior leadership management. Conducted various special performance improvement projects. Credentialing of Physician & Allied Staff for all five satellite clinics, including oversight and monitoring of their Medical Malpractice Insurance Coverage, and assisted with on-boarding physicians and other medical and non-medical staff.

Achieved greater than 95% accuracy performing Quality Medical Case Reviews.

Achieved greater than 95% accuracy investigating & responding to Grievances & Appeals review requests from various health plans

Developed system & process tool to facilitate credentialing processes

successfully implemented a process for tracking and trending the occurrence of grievances and incidents

Self Employed - Private Duty Nursing - August 2013 – May 2021

Private Duty Nurse

Provided compassionate, quality nursing Care.

Heritage Provider Network, Northridge, CA. November 2012 – July 2013

Quality Improvement Nurse Specialist

Led organizations in achievement of quality outcomes as a representative of a healthcare Accountable Care

Organization operating under a limited Knox-Keene license in California.

Processed and responded to patient health plan grievances including appeals denials. Orchestrated all facets of quality initiatives and created a quality framework to ensure compliance with all applicable state and federal regulations and accreditation standards. Performed Medical Facility Site Audits concerning various contracted Health Plans. Developed Clinical Work Plans Evaluations & Corrective Action Plans and conducted medical case reviews, Created and implemented quality metrics and continuous improvement plans. DMHC Grievance and Appeals, and NCQA/P4P Quality reviews. Performed utilization reviews utilizing Milliman and InterQual Clinical Guideline Criteria and utilized SIMS Criteria Guidelines in evidence-based practices, Also, conducted Credentialing and Medical Facility Site Audits.

When case census was low, I supported Case Managers by, educating, and enrolling members with chronic diseases in the “Vital Care,” a Chronic Disease Management Outreach Program, conducted patient needs assessments, medication compliance & care plans, provided education on risk prevention to patients, their families and on-going management of case files assigned to me, and processed pre authorization request for medical services.

Realized 95% success rate for enrolling members in “Vital Care” Chronic Disease Management Program.

Received commendation for achieving 98 % success rate in improved patient outcomes for “Vital Care” Program

Performed HEDIS P4P Dataset Abstraction Audits and collaborated on launching implementation of CMS Star Rating System. Developed Metrics Tools for abstracting and measuring quality measure dataset for Medicare Advantage Plan. Received commendation for excellence.

Achieved greater than 95% accuracy performing Quality Medical Case Reviews.

Successfully implemented quality improvement initiatives to ensure Program compliance and promote delivery of patient-centered care

Medassurant, Inc./Inovalon, Inc., Bowie, MD June 2011 – February 2012

Site Review Consultant – Assigned to Colorado Region

Propelled forward progress for a national healthcare data analytic solutions organization, focused on improving clinical and quality outcomes, financial performance for health plans and healthcare organizations and regulatory compliance.

Supported Quality Management Programs to achieve continuous quality improvement, Performed Medical Facility Site Audits & Prepared Healthcare Facilities for Regulatory Compliance Audits patient safety, and evidence-based patient-centered care, while also identifying outcomes for patient care delivery best practices. Completed HEDIS P4P Dataset, HCC, Payment integrity Audits.

Led team efficiency projects to reduce costs in delivering evidence-based patient centered care

Implemented Hierarchical Condition of Chronic Diseases (HCC ) Training Program For new hires

Led Team annual HEDIS P4P audits, receiving commendation for excellence in completing audits

Achieved above 95% accuracy for performance on HEDIS, HCC & Payment integrity Audits

Enhanced success by providing high quality, well-timed service for internal and external Clients.

Received commendation for timely completing projects prior to project end dates.

Received commendation for excellence for “Extraordinary Customer Service

Received commendation for the accuracy of audits conducted above the 95th percentile measured by inter rater reliability outcomes.

Kaiser Foundation Hospitals, Panorama City, CA August 1999 – March 2011

Quality Analyst

Not-for-profit health care organization operating medical centers in California, Oregon and Hawaii and other outpatient facilities in regions served by the Kaiser Permanente Consortium.

Designed and executed quality improvement program for member services department to enhance member relations, mitigate risk related to member grievances, improve timelines in processing grievances, and meet Department of Managed Care compliance standards. Also, developed system for performing Quality Case Reviews. Provided education, counseling, and support services to physicians and staff, pertaining to compliance with all applicable regulations and standards. Designed, executed, and enforced policies and procedures to promote patient safety and efficient operations. Abstracted core measures and ensured compliance with National Patient Safety Goals. Led cross-functional teams in PI and change management projects.

Created/implemented metrics tools for abstracting quality measures, including those for TJC & CMS Core Measure Dataset, and conducted audits. Acknowledged for quality measure benchmarks. Received commendation for excellence.

Played key role in securing four-year re-accreditation with commendation from the Institute of Medical Quality (IMQ) and California Medical Association (CMA).

Spearheaded annual HEDIS and CSG audits for main hospital medical center and (9) nine satellite medical clinics, resulting in a commendation for excellence and successful Accreditation.

Led innovative efficiency project that reduced cost savings by 25% across the foundation.

Realized 32% in revenue savings by securing and continuing key contract government contracts for the foundation.

Collaborated on establishing a pneumonia pilot study that was adopted as a best practice at other medical centers.

Developed & implemented Extraordinary Customer Service Training and Regulatory Compliance Training Program.

Achieved above 95% accuracy in performing Medical Correlation, Peer Quality Reviews, HEDIS, CMS Core Measure Abstraction, and DMHC reviews.

Miraflour & Associates, Diamond Bar, CA May 1993 – August 1999

Consultant

Healthcare Services Organization providing Full Line of Regulatory Compliance Services to Healthcare care Organizations.

Led team efficiency projects, Provided Regulatory compliance education support services to clinicians and staff, Conducted Medical Facility Site Audits & Prepared Healthcare Facilities for Regulatory Compliance Audits, Developed Corrective Action Plans, Introduced and implemented evidence-based best practices in delivering patient centered care, Designed and implemented various special performance improvement projects. When indicated, acted as interim Director, Case Manager and Risk Manager until the positions were filled

Areas of Focus

Regulatory/Standards Compliance

Clinical Work Plans Evaluations

DHCS Facility Site Audits

Corrective Action Plans

Accreditation Survey Preparation

Project Management

Case Management/Discharge Planning

Quantitative & Qualitative Analysis

Quality & Utilization Management

Systems & Process Development

Strategic Planning & Execution

Risk Mitigation

Staff Development & Leadership

Documentation Processes

Education

Distance Learning Program: Bachelor of Science in Nursing & Healthcare Administration

The College Network – Regis University. Denver, Colorado

Vocational Nursing Program

Concorde Career Institute - Los Angeles Valley College

Master of Business Administration Mini Program

University of Southern California Los Angeles, Graduate School of Business Administration, Los Angeles, CA

School of Public Health – Management & Administration of Health Care Organizations

University of Southern California Los Angeles, Los Angeles, CA

Licenses & Certifications

Licensed Vocational Nurse: State of California & Licensed Practical Nurse - Compact Multi-State License

BLS Certified & IV & Blood Withdrawal Certified

Certificate in Case Management & Discharge Planning

Certified Professional Medical Auditor (CPMA

Certified Professional in Healthcare Quality (CPHQ) - Course Completed

Affiliations

Member, American Society for Quality Global Leader in Quality Standards (ASQ) • Member, Case Management Society of America (CMSA) • Member, American Academy of Professional Coders (AAPC) • Member, National Alliance of Medical Auditing Specialists (NAMAS) • Member, Association for Clinical Documentation Improvement (ACDIS) • Member, Institute for Healthcare Improvement

Honors & Awards

Elite American Health Professionals – 2011

Cambridge Who’s Who: Professional of the Year for Healthcare Regulatory Compliance – 2010 & 2011

Former Occupational Specialist for Re-Accreditation, North - West Colleges - 4 Campuses

References Available Upon Request

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