Rajat Dhameja Resume



Cell: 714-417-3117




Decisive, action oriented and results focused Health Services professional offering stellar academic background and over 7 years of healthcare experience in Managed Care and Clinical settings. Experienced in Project Management, Process Improvement, Product Development, and Quality Improvement, Regulatory Affairs, Compliance, Strategic Planning and Provider Contracting. Ability to work broadly across wide portfolio of projects with teams in Operations, Finance, Customer Service and IT. Ability to perform Financial Reporting, Data Analysis and Forecasting to drive decision making. Adept Negotiator and Critical Thinker who can apply extensive knowledge and industry trends to rapid revenue and profit growth opportunities.



Contract Negotiation ● PPO, HMO Reimbursement ● Medicare & Medicaid Programs

RFP Process ● Client Relationship Management ● SWOT Analysis / Market Analysis  ● Predictive Modeling ●  Clinical Decision Support  ●  NPV, EBITDA, ROI, IRR ● Cost Benefit Dimensions

Policy & Procedure Audits ● Internal Medicine, Surgery, Ob/Gyn ● DRG, APC, ICD-9-CM, HCPCS

Acute & Ambulatory Care ● Presentations to Senior Management and Leadership

MS Excel ● Access ● SQL Query ● Power Point ● Outlook ● Word ● SharePoint





M.H.A – Master of Health Administration

University of Southern California (USC), School of Policy, Planning and Development, Los Angeles, CA, 2007


Post-Graduate Administrative Residency – Leadership Track

  1. A. Care Health Plan, Los Angeles, CA, 2006 – 2007


M.B.B.S / MD – Bachelor of Medicine, Bachelor of Surgery Medical Degree

Faculty of Medicine, Kasturba Medical College, Manipal University, India, 2001

Equivalent of United States MD (Doctor of Medicine)




Healthcare Consultant & Project Manager                                                         2009 – 2013


  • Provide consulting as council member of GLG consulting group
    • Provide front-line subject matter expertise to leading healthcare companies including Managed Care Industry, Hospitals, TPAs, Medicare and Medicaid Services
    • Achieve maximum consulting credibility, client satisfaction and recognition by way of adherence to industry standard consulting protocols.
  • Assistance to confidential US based client in Business Development in the middle-east
    • Promote Knowledge Development and Thought Leadership through individual assignment.



Summary of Consulting Assignments 2009 – 2013


Sr. Consultant, Clinical Programs PMO, Molina Healthcare, Inc., Long Beach, CA

Lead full lifecycle of Clinical Systems projects to support business process owners and leadership initiatives for Medicaid, SPD, MMP and Medicare lines of business. These include MEDai® Predictive Modeling, Chronic Illness and Disability Payment System® and Clinical CareAdvance® for risk stratification and care management activities. Presented monthly status reports to Business Executive Steering Committees and Leadership.


Consultant: Ace Heart & Vascular Institute, India                                                                    

Assisted in setting up a new state of the art cardiothoracic and vascular surgery hospital providing a comprehensive mix of inpatient and outpatient services.


Joint Commission Accreditation (formerly JCAHO)

Assisted consulting firm with developing comprehensive project plans for adoption of US accreditation standards by client hospitals, pharmacies, clinics and blood banks. This was a phased approach from Initiation to Completion including preparing project documents, performing financial and complex data analysis, developed budget proposals, identified core performance measures for QI standards and Corrective Action Plans.


ACHE Communications Chair (Voluntary)

Developed and Maintained Content Management System and website for Missouri Chapter. Served as communications committee chair, developed quarterly newsletters, facilitated dialogue and communication aspects between healthcare organizations, staff and leadership, analyzed membership growth data and assisted board members in meeting chapter’s strategic goals.


Patient Centered Medical Home                                                                    

Assist client in achieving Quality Improvement benchmarks and Regulatory requirements in compliance with Healthcare Reform. Process Improvement documentation such as Consultations, Referrals, Transition of Care and Health Outcomes Analysis


ACHE (American College of Healthcare Executives)                                                    2009 – 2011

Chair, Communications Committee


  • Oversee and maintain communication activities among chapter members through web services, publications, electronic mail, and other delivery mechanisms to ensure effective and timely communication among the chapter members.
  • Provide direction, develop project plans and set priorities for chapter’s strategic goals.
  • Recommend new opportunities and technology to enhance internal and external communications.


EXPRESS SCRIPTS, INC., St. Louis, MO               

Senior Manager, Product Development                                                                         2008


  • Assumed responsibility to strengthen Medicare Part D product offering, increase confidence of internal and external clients and CMS compliance adherence.
  • Headed Medicare Product’s large scale Financial Information Reporting project to automate transfer of true out-of-pocket and total drug costs, led IT and Product teams toward CMS certification for implementation.
  • Performed plan rating analysis with emphasis on frequency of drug pricing changes and identified Generic MAC as critical variable.
  • Achieved approvals for 3 new process improvement projects presented to Project Review Board, estimated at $150 – 225K each.
  • Maintained approximately 12 current processes including high revenue generators such as Explanation of Benefits (EOB), CMS Reporting and Coordination of Benefits.
  • Developed EOB Inserts as new product development for upsell to clients together with marketing and communication package estimated at $160K in additional revenues.
  • Participated and presented project plans and deliverables on internal calls, external client calls and industry task force groups (NCPDP, PCMA, CMS).
  • Collaborated with Legal and Compliance on internal audits, identified gaps and approved new action plans including training of personnel.


  1. A. CARE HEALTH PLAN, Los Angeles, CA

Administrative Resident                                                                                                   2006 – 2008                                                

  • Managed Predictive Modeling project for implementation of clinical system based on risk adjustment methodology to identify and stratify high risk members, forecast future utilization, reduce cost and improve clinical outcomes.
  • Developed project plan and schedules, drafted RFP, managed deliverables.
  • Analyzed vendor proposals based on Adjusted Clinical Groups, Expanded Diagnosis Clusters, Diagnosis Cost Groups, Episode Risk Groups and Pharmacy Risk Groups.

Strategic Planning

  • Project team member for large scale, cross-functional pilot initiatives chartered to drive performance improvement, financial gains and member satisfaction.
  • Estimated budgets, cost projections, performed time-value and cost-benefit analysis.
  • Researched competitive landscape and developed strategic product concepts.


Quality Improvement

  • Designed Physician Advisory Committee model to enhance quality of programs and interventions; provide feedback on clinical and administrative initiatives.
  • Developed Mental Health Toolkit incorporating current Clinical Practice Guidelines.
  • Provided project management support for NCQA accreditation strategy.


Provider Network Operations

  • Assisted in developing organization’s Medicare Advantage (MA) – Special Needs Plan (SNP) by way of contract amendments to expand existing product lines.
  • Negotiated contracts with Ancillary and Specialty providers.

Regulatory Affairs and Compliance

  • Revised L. A. Care Health Plan’s Compliance Program Description for new Medicare Advantage Plan application to CMS. Incorporated OIG requirements of conduct, policies, procedures, monitoring, auditing internal reporting and corrective action plans.
  • Participated in Clinical Editing Task Force to ensure appropriate payment and coding.



Intern (Medical Claims Review Specialist)                                                                       2006

  • Performed DRG Validations, specifically identifying up-coding as cost-containment effort toward targeted savings of $9 million in 2006.


FMCEA (Now known as Hospital Clinical Services Group), San Diego, CA        

Certified Clinical Autotransfusion Specialist                                                                   2003 – 2005

  • Performed over 300 autologous blood transfusion procedures independently during Orthopedic and Vascular surgeries.
  • Documented procedure records, vendor communication and managed inventory control.


KASTURBA HOSPITAL (Academic Medical Center), Manipal, India

Physician                                                                                                                           2000 – 2001

  • Direct patient care in ambulatory and acute care settings including in-patient, emergency room, critical care, intensive care, neonatal and burn ICU.
  • Outstanding training through rotating clinical internships in Internal Medicine, General Surgery, Ob/Gyn, Pediatrics, Anesthesiology, Orthopedics and Preventive Medicine.
  • Obtained complete medical history, performed physical exams, made case presentations, proposed differential diagnosis, developed rational plans for diagnosis, implemented therapy based on etiology, pathogenesis and clinical manifestations.
  • Participated in daily Morning Report sessions with residents, attendings and faculty physicians, weekly Grand Rounds, daily Case-Based Teachings and Intern Reports.




  • ACHE (American College of Healthcare Executives)
  • USC Alumni Association, School of Policy Planning and Development
  • GLG Group, Healthcare Council Member
  • HFMA (Healthcare Financial Management Association)
  • US Squash Players Association
  • MGMA (Medical Group Management Association)




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