GRACE A. KOCH BSN, RN, CPDM, CCM
PO Box 2098, Corvallis, OR 97339
P  [Send email to request phone number] 53-1524 , F  [Send email to request phone number] 38-0524

STATEMENT OF QUALIFICATIONS

Experienced health care professional with extensive and progressive experience
in utilization review, regulatory requirements, auditing and analysis of employer
group health plans, quality assurance, workers' compensation, personal injury,
insurance claim reviews, documentation and advocacy process; medical/legal
educator.

PROFESSIONAL EXPERIENCE

GRACE A. KOCH RN, CONSULTING, Corvallis, Oregon.
Regional healthcare consulting firm specializing in clinical audit review to
facilitate health plan beneficiary advocacy programs and stratagems for profit
recovery.
Medical Consultant, 2007-Current
 * Manage Oregon DHS TANF/Temporary Assistance for Needy Families and SSP/Self
Sufficiency Program clients whose medical issues may hinder their ability to be
employed and self sufficient, for Lincoln and Benton Counties.
 * Communicate with medical professional providers to help identify the validity
of the client's medical condition, as well as provide clarification for DHS case
managers to facilitate the appropriate recommendations for services to aid the
client in becoming self-sufficient.
 * Trained Leader: Stanford Chronic Disease Self-Management Program.

SAMARITAN HEALTH PLANS, Corvallis, Oregon.
A state licensed regional Third Party Administrator insurance company with four
specialized plans which include Medicare and Medicaid serving 250,000 people in 3
counties and employing 100.
Utilization Review RN, 2006-2007
 * Perform prospective and retrospective reviews utilizing McKesson/Interqual
Acute Care Criterion for Inpatient Admissions, Imaging and other Procedures, all
plans as appropriate and
make decisions for acceptance or referral for Physician Review.
 * Perform Utilization Review for specialized health plans for Home Health,
Skilled Nursing, Intermediate Care Facility Therapies, Occupational Therapy and
Physical Therapy benefit requests in a like manner.
 * Initiated advocacy process on behalf of infant member requiring compounded
cardiac medication which resulted in a company policy change to provide safe
discharge, improved services, integrated care, and contain costs.
 * Facilitate and promote Education, Quality and Performance Improvement
Programs.
 * Participate as part of the Managed Care Team.

MERCY MEDICAL CENTER, Roseburg, Oregon.
Community based medical center with a 174 bed capacity, owned by the Catholic
Health Initiatives focusing on well health care and community outreach employing
1,000 people.
Clinical DRG Management Specialist, 2005-2006
 * Planned, and Implement DRG Management.
 * Performed prospective reviews utilizing McKesson/Interqual Acute Care
Criterion for patient admission, and retrospective reviews for appellate
purposes.
 * Data established empirical justification for establishment of a new hospital
unit for Clinical Decision/Observation Status.
 * Facilitate and promote the work of the Utilization Management Team.
 * Participate as part of the Clinical Strategy Team & Decision Support Group.

OREGON PATIENT SAFETY COMMISSION, Portland, Oregon.
Semi-independent state agency charged with improving patient safety by reducing
the risk of adverse events occurring in Oregon's health care system and by
encouraging a culture of patient safety in Oregon.
Researcher, 2004-2005
 * Provide research as asked for the Principal Contributor and Commissioners.

WMCI PRIME EVALUATIONS, Portland, Oregon.
Privately owned medical consulting firm founded in 1985 which offers physical
examination services for insurance companies in Oregon with offices in Portland,
Salem, Eugene, Grants Pass, and the states of Washington, Arizona, Colorado and
Utah with annual sales of $500,000-$999,000, and employing 57 people.
Quality Assurance Program Supervisor & Legal Nurse Consultant, 2001-2002
 * Supervised specialists in Medical Records and Quality Assurance Departments,
concurrently performing Legal Nurse Review for attorney clients.
 * Aided physicians to identify issues of concern under Medicare, ADA, FMLA,
long and short term disability, workers' compensation and other employer group
health plans.
 * Planned and implemented improved Quality Assurance procedures which
stratagems reduced addendum reports, administrative costs and a decrease in
product turnaround time to the client.

CAMBRIDGE MANAGED CARE, Genex, Kemper, Portland, Oregon.
Major national healthcare organizations utilizing registered nurses to
facilitate recommended treatment plans to assure appropriate care is provided to
disabled, ill, or injured individuals.
Case Management Nurse, 1996-2001
 * Coordinated medical care services to disabled individuals under Medicare,
ADA, FMLA, workers' compensation, group health, long & short term disability and
other employer benefit plans.
 * Identify gaps in the standard of care in regard to issues related to
documentation, necessity of treatment, negotiating contracts, resulting in
improved patient safety, medical services and client satisfaction.
 * Facilitated employer return to work programs using creative disability case
management case specific techniques to contain indemnity and medical costs.
Maintained 108% production with lower per case costs.
 * Achieved Kemper's highest corporate rating for field case management.

AMERICAN INTERNATIONAL GROUP, Portland, Oregon.
A world leader in insurance and financial services with operations in 130
countries serving commercial, institutional, and individual customers in life,
property and casualty insurance, title and mortgage networks.
Divisional Legal Nurse Consultant, 1993-1996
 * Provided written analysis of complex medical-related insurance claims issues
encompassing appropriateness of treatment, injury causation, missing records,
medical malpractice, product liability, disease or treatment process research,
and toxic tort.
 * Reviewed complex medical claims using innovative Legal Nurse Processes and
providing written recommendations for further investigation and case resolution
and resulted in defense counsels' ability to use clinical analysis as part of
trial preparation.
 * Created medical-legal educational programs using knowledge of adult learning
needs. Achieved accreditation from the Oregon Bar, NARPPS, and the
Recertification Program for Claims Examiners for Oregon and featured by the CEO
in the newsletter, "AIG Claims Chronicle."

RELIANCE/UNITED PACIFIC INSURANCE COMPANY, Portland, Oregon.
Major national property and casualty insurance operation with developing
subsidiaries in real estate and international group subsidiaries in energy,
environment and natural resources consulting.
Senior Claims Representative, Workers' Compensation., 1986-1991
 * Processed claims from inception to conclusion including Board's Own Motion.
 * Utilized nursing knowledge of disease processes in processing claims
resulting in lower litigation incidence, reduced claim indemnity, medical and
legal costs.

Clinical Nurse, 1976-1993
 * Relief Charge Nurse, Team Leader, and Residential Manager.
 * Clinical Areas: Includes Acute Care, Ortho/Neuro, Med/Surg, and Community
Health.

EDUCATION

BSN/Oregon Health Sciences Center,1976, Portland, OR
CCM/ Commission for Case Manager Certification, Portland, Oregon 2002.
CPDM/ Insurance Education Association, Portland, Oregon 1999.

MEMBER
American Society for Healthcare Risk Management
Oregon Society for Healthcare Risk Management
American Association of Legal Nurse Consultants
Oregon Nurses Association
Oregon Medical Case Manager's Group
Case Management Society of America