About

10/01/2013 – Current

• Consultation services to companies regarding healthcare, compliance, and medical devices.
• Sub-specialty medical reviews in Pulmonary and Critical Care Medicine. Independent Consultation services for multiple managed care organizations and insurance companies, including employment at various companies Aetna, AllMed, Expert, Dane Street, etc. in medical reviews.
• Lecture and consultation to device/medical technical companies and insurance issues private utilization, etc. and Medicare in fraud and abuse.
• Provide expert witness and medical file reviews.

• Assisted in managing a strategic relationship from a patient management company that became a manage care organization.
• Performed administrative activities, lead coordination of departments and reported to the CFO and board of directors.
• Assured legal CMS/Medicaid and State of Illinois guidelines and criteria were implemented and met. Attended state of Illinois quarterly meetings for ACO.
• Engaged with IT technology for databased management when converting from a patient management system to a managed care organization.
• Worked closely with hospital staff, department directors, and physicians to ensure that the highest standards of quality and service are maintained.
• Established interdisciplinary care teams, while transitioning to managed care and providing education for the staff.
• Worked to improve clinical performance and maintain compliance with HIPAA, (Health Insurance Portability and Accountability Act), and other accreditation standards.
• Performed review and maintain URAC standards for both Health Management and Credentialing.
• Provided on-call services that involved timely concerns outside of the regular scope of business times to assure we were in compliance and best patient health outcomes could be achieved in receiving timely care.
• Approved policies developed within various sub-functions and departments.
• Worked to implement cost-effective, efficient medical interventions while maintaining optimum health care. (high outlier reviews and intense case management with home and family involvement).
• Maintained neighborhood healthcare facilities relationships and collaboration with University Hospitals and teaching systems. (University of Illinois, Mt. Sinai Medical Systems, etc.) to promote engagement and growth.
• Worked with provider network department not only to increase network but to fill deficiencies and assure network adequacies.
• Worked with Pharmacy and PBM. Worked with pharmacy for pharmacy benefits, and special pharmacy committees to monitor and assess best practice analysis, patient compliance, safety, and cost-effective utilization. Ensure state and national policies for pharmacy and protected class drug.
• Enforced and reviewed the clinical guidelines and protocols.

I was a pharmacy medical director and worked with a contracted Pharmaceutical Benefit Managers (PBM), and for the overall effectiveness of the pharmacy operations and programs. Additionally, this position requires collaboration with management and professional staff within HCSC and with external health care providers to improve quality of healthcare, optimize health outcomes and improve the cost of care.

• Reviewed pharmacy determinations for Montana, Oklahoma, New Mexico, Texas, and Illinois.
  • Engaged with the P&T (pharmacy & therapeutics) committee, Technology assessment committee and PMB Pharmacy Management Benefit (PMB).
  • Created plans to complete timely and accurate assessment of pharmacy benefits and therapy, complying with all state and federal guidelines.
  • Included specialty drugs to aid in reimbursement, services tailored to patients, their disease ensuring safety and healthy outcomes.
• Applied state mandates and Blue Cross Blue Shield Clinical Policies and National guidelines Professional Medical Society Position Papers.
• Conducted peer to peer reviews with the network medical physicians and providers.
  • The reviews and assessments included drugs covered under the medical benefit and the pharmacy.
  • This not only involved drug utilization review but the coverage requirements (disease states companion testing etc.)
• Drugs requiring Risk Evaluation and Mitigation Strategies (REMS) were evaluated as well as medication for members special needs referred additional services (eg, nursing) that will be required to support the drug and product Durable Medical Equipment (DME).
  • Location or point of service for care was reviewed for appropriateness of care and provide for optimum health care delivery.
  • Prior authorization and specialty authorization step edit programs consistent with member’s plan documentation were provided
  • Peer review with providers physicians, hospitals and other healthcare facilities were performed.
  • Appeals reviews for pharmacy and medical management were conducted.
• Provided on-call services for pharmacy management that involved timely concerns outside of the regular scope of business times to assure we were in compliance and best patient health outcomes could be appropriately achieved in receiving timely care.

• Provided clinical leadership for the utilization management process of all ages, including pre-authorization, denials and appeals, specialty and sub-specialty reviews with medical determinations using nationally published and recognized clinical guidelines.
  • Utilization review also included evaluation of the health history, diagnosis, pharmaceutical utilization, and medical device review for appropriateness of medical services.
  • These reviews covered medically necessary services and location of facilities: in-patient, out-patient, in-home health service.
  • Theses reviews encompassed concurrent reviews and retroactive reviews involving acute care, long-term care as well as chronic care. Reviews were with all plans of business including HMO, PPO, Specialty networks, and joint collaborative projects as well as Medicare.
• Conducted appeal reviews and hearings, from physicians, patients, hospitals and other vendors or providers as well as peer to peer reviews. Provided assessment of risk management in medically and surgically complex cases, to achieve the best clinical outcomes while controlling cost as measured through data analysis.
• Coordinated medical with psychological/behavioral health plan benefits for improved patient outcomes for 2 years.
• Administered case reviews consistent with the Health Insurance Portability and Accountability Act with providers, patients, and staff.
• Member of Aetna’s clinical Policy Bulletin Committee, clinical policy research, analysis and clinical program development, and applied principles in utilization reviews.
• Provided clinical direction and guidance to nurses and other staff for utilization and interpretation of protocols.
• Involved with credentialing and re-credentialing of physicians.
• Worked with the pharmacy for pharmacy benefits and participated in pharmacy committees to monitor and assess best practice analysis, patient compliance, safety, and cost-effective utilization.
• Supported and provide clinical expertise in disease management, case management, and re-admission programs.
• Analyzed data to identify opportunities for quality improvement for positive effective delivery of healthcare.
• Engaged in quality metrics to assist in achieving NCQA accreditation.
• Collaborated with other functional areas that interface with medical management including facility and network relations, contracting, member services, sales, benefits and claims management, healthcare delivery, national medical services and national accounts to achieve quality care.