Rachel Ortega

• Provided strong leadership to enhance team productivity and morale.
• Led cross-functional teams to achieve project milestones and deliver high-quality results.
• Established strong relationships with clients and stakeholders, ensuring long-term partnerships and repeat business.
• Improved team performance by providing comprehensive training and fostering a collaborative work environment.
• Collaborated closely with peers from other departments to drive organizational success jointly as one cohesive unit.
• Reduced costs, optimized resource allocation, and improved efficiency in managing projects.
• Managed large-scale projects and introduced new systems, tools, and processes to achieve challenging objectives.
• Mentored junior staff members for skill development and career progression within the organization.
• Implemented and developed operational standards, policies and procedures.
• Achieved operational excellence by streamlining processes and implementing best practices.
• Demonstrated exceptional adaptability in navigating complex situations or rapidly changing environments with ease.
• Conducted performance evaluations, compensations and hiring to maintain appropriate staffing requirements.
• Balanced competing priorities efficiently while maintaining focus on critical tasks requiring immediate attention.
• Increased customer satisfaction with timely project deliveries and seamless communication.
• Implemented innovative solutions to overcome challenges, leading to enhanced productivity levels.
• Promoted a culture of continuous learning through regular workshops, seminars, and training sessions for staff.
• Reviewed and analyzed reports, records and directives to obtain data required for planning department activities.
• Championed process improvement initiatives that led to significant cost savings without compromising on quality standards.
• Boosted team member productivity by enhancing performance monitoring and instituting motivational approaches.
• Spearheaded change management efforts for seamless adoption of new systems or processes among employees.
• Improved team productivity by implementing agile methodologies, reducing project completion times and enhancing collaboration.
• Drove adoption of new technology solutions, modernizing operations and improving operational efficiency.
• Enhanced team performance with regular coaching sessions, focusing on individual strengths and areas for improvement.
• Streamlined internal processes for financial reporting, ensuring accuracy and compliance with regulatory standards.
• Established performance goals for employees and provided feedback on methods for reaching those milestones.
• Evaluated employee performance and conveyed constructive feedback to improve skills.
• Planned, created, tested and deployed system life cycle methodology to produce high quality systems to meet and exceed customer expectations.

• Enhanced client satisfaction by implementing innovative strategies and tailored solutions for their unique needs.
• Evaluated emerging industry trends and technologies, incorporating relevant insights into strategic planning for sustained competitive advantage.
• Strengthened relationships with key stakeholders through regular communication and collaboration on mutually beneficial projects or initiatives.
• Streamlined internal processes with the implementation of efficient project management techniques, reducing overall costs and increasing productivity.

• Managed and assigned/delegated work to Account Coordinator. Contributed to Account Coordinator’s annual performance review. Granted time off when Sr. Account Manager was unavailable
• Provided direction, guidance, and training to the Account Coordinator to resolve billing, member, and enrollment related issues.
• Supported the Sr. Account Manager in a back-up capacity in all aspects of account management.
• Managed Kaiser Permanente’s business relationships with primary and secondary decision-makers from Labor & Trust Purchasers to increase enrollment and build strategic partnerships.
• Built effective customer relationships with large existing account branch locations and union locals in order to retain and build membership.
• Coordinated the implementation of account renewal strategies with appropriate internal resources, including pricing, RFP, contracts, billing and eligibility, and medical center departments.
• Assisted Account Manager in the development and execution of strategic account plans and the tracking of activity progress throughout the year.
• Utilized and accurately summarized key competitive data for management in a timely manner that assisted in achieving desired account results.
• Presented enrollment and benefit information to Labor & Trust members during open enrollment.

• Evaluated client needs and expectations, establishing clear goals for each consulting engagement.
• Liaised with customers, management, and sales team to better understand customer needs and recommend appropriate solutions.
• Collaborated with cross-functional teams to successfully deliver comprehensive solutions for clients.
• Managed client relationships through regular check-ins and updates on project progress.

Kaiser Foundation Health Plan, Inc. Pasadena, California

Regional Compliance and Privacy, Health Plan Compliance February 2011-October 2012

Senior Consultant

• Served as Regional Compliance Office (RCO) lead for Health Care Reform risk assessments, implementation validation, corrective action plan management, gap analysis, and reporting.
• Analyzed and documented state health care reform requirements/regulations for use by National Compliance Audit Team.
• Developed compliance resources such as the root cause analysis tool utilized by the various compliance organizations and functional areas to identify root causes of non-compliance.
• Provided consultative support to Utilization Management (UM) Compliance Directors on various compliance functions such as training, education, root cause analysis, risk assessment, and policies and procedures.
• Participated in the California Health Plan Compliance Committee (HPCC).
• Monitored UM compliance performance through analysis of quarterly (HPCC) presentations.
• Prepared Utilization Management Compliance Directors for formal compliance risk presentations to the (HPCC).
• Develop process flows for certain Health Plan Compliance (HPC) functions such as Health Care Reform risk assessment and audit activities to promote consistency and efficiency when working on complex processes with multiple compliance organizations.
• Served as lead for the annual National and Regional Compliance risk refresh process to identify new risk and refresh existing risk for all HPC functional areas including, Utilization Management, Clinical Review, California Claims Administration (CCA), Member Services, Provider and Hospital Contracting, Cultural Diversity and Linguistics, and Pharmacy. Created risk refresh tools such as risk refresh desktop reference.
• Analyzed internal and external audit reports to identify trends across business lines.
• Developed and maintained Health Plan Compliance’s work plan (HPC compliance initiatives).
• Represented the Regional Compliance Office/Health Plan Compliance on the MSSA Compliance and Regulatory Community of Practice Meetings and report out on RCO Health Care Reform compliance activities.
• Researched, analyzed, identified key findings, and recommended action steps to resolve various compliance issues assigned to Health Plan Compliance by the Southern California Regional Compliance Officer and Vice President, Public Relations, Legal, and Medical Center Compliance Officers.

• Mentored junior consultants, helping them enhance their skills and contribute more effectively to projects.
• Delivered high-quality solutions for clients through comprehensive research and analysis of industry trends.
• Developed innovative strategies to address complex business challenges, resulting in increased profitability for clients.
• Presented findings and recommendations to executive-level stakeholders, effectively communicating key insights and action plans.

• Developed, managed, and coordinated benefits in consultation with the Southern and Northern California Medical Groups (SCPMG/TPMG), Hospital and Health Plan Leadership.
• Developed comprehensive profiles in collaboration with SCPMG and TPMG Operations, various system administrators (HealthConnect, Foundations, PIMS), Pricing, Decision Support, Regulatory, Legal, and clinical staff for review by the Benefit, Contract, and Policy Committee (BCPC).
• Conducted market/industry benefit analysis when the Competitive Assessment Department could not meet established deadlines.
• Solicited input from those affected by benefit and/or policy change to educate, obtain buy-in, and minimize fears and resistance regarding the change.
• Interpreted benefits, including drug, reconstructive surgery, dental, outpatient surgery, inpatient hospital, dermatology, mental health, chemical dependency, emergency, and ambulance for internal stakeholders such as SCPMG, TPMG, Member Services, and Sales & Marketing.
• Ensured integrity of member contract, Evidence of Coverage (EOC), was maintained by monitoring and enforcing proper administration of health plan benefits.
• Reviewed annual member EOC benefit language changes for accuracy.
• Ensured regulatory compliance of Health Plan benefits/policies with the Knox-Keen Act, Federal HMO Act; Centers for Medicare and Medicaid Services (CMS) and Department of Managed Health Care (DMHC) requirements.
• Developed and maintained Health Plan Alert policy and process flow to ensure that accurate and timely benefit change information was communicated to the appropriate stakeholders.
• Developed Annual Global Benefit Changes Alert and training materials.
• Presented benefit changes to various multi-level stakeholders.
• Facilitated the Joint Pharmacy Benefit Committee Meeting, created time lines, and tracked initiatives/deliverables to completion.
• Provided benefit data for submission to the California Health Benefits Review Program within extremely tight turnaround times.
• Provided weekly consultation to the Southern and Northern Regional Appeals Committees (RACs).
• Attended quarterly Regional Southern and Northern Pharmacy and Therapeutics Committees (P & Ts) to identify potential benefit issues and interpret benefits/policies as requested by P & T Chairs.
• Attended the Regional HIV/AIDS Management Committee and provided benefit consultation as requested by committee Chair and staff.

• Served as case manager in the investigation, preparation, and presentation of cases for medical or legal review.
• Processed and resolved grievances, appeals, and member satisfaction issues.
• Maintained excellent files that met regulatory guidelines.
• Participated in and reported to the Medical Center Review Committee for physician determination of cases.
• Interacted with all levels of staff and management throughout the medical center.
• Assisted members in their interaction with medical providers and administrative personnel.

EKG Technician

• Performed electrocardiograms (EKGs) in inpatient, outpatient, and emergency settings.
• Responded to code blue and medical response team alerts.
• Assisted Cardiac RN with Treadmill Stress Tests.
• Attached holter and trans-telephonic monitors and provided instruction to members on use.
• Assisted EKG Technician II with pacemaker checks.

Receptionist II

• Scheduled appointments and took phone messages for physicians.
• Provided instructions to members to prepare for cardiac and GI procedures.
• Checked eligibility and registered members.
• Processed registration slips to determine billing status of the member.