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Medical Director Manager at Cigna
November 2019 - Present
Area of responsibility includes all non-delegated Utilization Management (UM) reviews for all Medicare Advantage (MA) plans across the US.
 
The Medical Director Manager in Utilization Management (UM) will report to the National Senior Medical Director over UM and will lead the Medical Director UM team. This physician will be responsible for completing UM determinations and assisting with Appeals, when needed. In addition, this physician will serve as a key leader in the UM organization.
 
The Medical Directors in UM will work alongside their clinical and operational key partners and will be responsible for performing all key business and clinical initiatives regarding UM.
 
POSITION SCOPE:
The Medical Director Manager in Utilization Management (UM) will report to the National Senior Medical Director over UM and will lead the Medical Director UM team. This physician will be responsible for completing UM determinations and assisting with Appeals, when needed. In addition, this physician will serve as a key leader in the UM organization.
 
The Medical Directors in UM will work alongside their clinical and operational key partners and will be responsible for performing all key business and clinical initiatives regarding UM.
 
RESPONSIBILITIES:
  • The UM Medical Directors will support Cigna’s Medicare Business in Utilization Management and works with the clinical operations UM team in identifying opportunities of improvement related to the UM function.
  • Perform reviews for utilization management reviews including Part C prior authorization, inpatient concurrent review, and post-service reviews.
  • The UM Medical Director team facilitates UM consistently and compliantly using benefit plan information, applicable CMS and state regulations, clinical guidelines, emerging codes, new trends and best practice principles.
  • Performs proactive & reactive peer-to-peers for Part C prior authorization, inpatient concurrent review and post-acute prior authorization and concurrent review.
  • Works to achieve quality outcomes for customers with a focus on service and affordability.
  • The UM Medical Director team will help improve clinical outcomes through daily interactions with health care professionals using active listening education, excellent communication, and negotiation skills.
  • Works to achieve internal customer satisfaction and regulatory/accreditation agency compliance goals by assuring both timely turn-around of coverage reviews and quality outcomes based on those review decisions.
  • Aware of the Appeal process as appropriate and supports the Appeals Medical Director team, when necessary.
  • Participates in committees, work groups and special assignments representing UM for Cigna’s Medicare Business, where appropriate, and achieves professional and personal career growth by creating protected time to complete associated assignments and activities.
  • In conjunction with the National Senior Medical Director over UM develops, refines, reviews and acts upon utilization review reporting metrics both national and occasionally at the market level. These metrics should demonstrate operational effectiveness including financial analysis and provider and customer satisfaction analysis.
  • Collaborates with the National Senior Medical Director over UM and the Commercial UM Medical Directors to coordinate efforts to improve outcomes and affordability related to UM and it’s interaction with other functional areas.
  • Works in conjunction with external delegated entities to maximize effectiveness of the working relationship between both parties while promoting an environment of maximizing the member experience, quality, and professionalism.
  • Coordinates Medical Director team activity including but not limited to resource scheduling, call schedule management, coaching, and development of staff.
 
 
 
 
 
Senior Medical Director at Highmark Inc.
January 2018 - June 2019
Area of responsibility includes all contracted (non-employed) and employed physician groups across the US with over 260,000 Medicare Advantage (MA) members.
 
Responsibilities include:
  • Assist and lead, where appropriate, in the development, implementation and monitoring of the organization's short and long term clinical vision strategic business plans. Serve as a resource for information and consultation on issues relating to senior markets product offerings, clinical services and medical affairs, including such issues as product design, case management, condition management programs, health risk assessments and clinical care.
  • Assist in the design/implementation of advanced care/case management strategies throughout the network of practitioners/providers to ensure efficient and effective delivery of medical services. May review care/case management reports and develop action plans as needed and provide consultation to the team members by offering advice and assistance in achieving resolution of problem cases, and actively support care/case management activities.
  • In conjunction with other executives and local administration, conduct meetings, seminars, conferences, and facilitate other forms of group interaction among physicians in order to promote sharing of information and expertise, to foster program support, identify best practices and to enhance identity with Highmark.
  • Monitor clinical resource allocation, utilization and referral patterns, patient satisfaction, and clinical outcomes across the practitioner/provider network as it relates to the business. Develop understanding of current hospital and physician payment methodologies, and how they impact utilization incentives in the provider community for care.
 
 
 
 
Medical Director at WellMed Medical Management
March 2015 - December 2017
Area of responsibility includes all directly contracted (non-employed) physician groups in Dallas-Fort Worth with over 65,000 MA members.
 
As part of the executive leadership team:
  • Increased the number of contracted small-group primary care providers from under 20 to over 40 providers.
  • Increased the regional MA panel from under 30,000 to over 98,000 members.
  • Raised the market average Risk Adjustment Factor (RAF) score from below 0.8 to over 1.3.
  • Improved the combined HEDIS quality metrics by over 100%.
  • Raised CMS Stars from 4.0 to 4.5 Stars by 2018.
  • Increased area of responsibility from 3,000 members to over 60,000 members and from no direct reports to supervising 4 medical directors.
 
 
 
 
Associate Medical Director at MCCI
January 2013 - February 2015
Area of responsibility included 6 primary care medical offices with 12 physicians, 2 nurse practitioners, and over 5,000 Medicare Advantage ( MA) members.
 
As part of the executive leadership team:
  • Reduced medical loss ratio (MLR) from 98% to 86%.
  • Increased per-member-per-month (PMPM) funding from $865 to $898.
  • Increased membership by 13%.
  • Maintained 4.5 Stars Centers for Medicare and Medicaid Services (CMS) rating.
  • Increased bottom-line margin to $23.4 million.
 
 
 
 
Surgeon at South Florida Surgical Specialists
July 2010 - December 2012
Private practice. 1,350 operations over 2.5 years.
Physician champion for Computerized Physician Order Entry (CPOE), Health Information Management committee, Pharmacy and Therapeutics committee.
 
 
 
 
Surgeon at Osler Medical
May 2008 - May 2010
Private practice. 750 operations over 2 years.
Pharmacy and Therapeutics committee, Infection Control committee.
Established a new multidisciplinary weight loss surgery program. Performed over 50 laparoscopic weight loss operations.
 
 
 
 
Surgeon at CompHealth
December 2007 - March 2008
Locum tenens surgeon.
The Villages, the largest retirement community in the world, had a temporary shortage of surgeons. Short term position providing surgical care for a Medicare population.
 
 
 
 
Surgeon at Surgical Associates of North Florida
September 2006 - September 2007
Private practice. 600 operations over 1 year.
 
 
 
 
Surgeon at United States Air Force
Surgeon: August 2002 - August 2006
Active duty. Eglin Hospital. Lieutenant Colonel.
Deployed to the Middle East for Operation Iraqi Freedom. Air Force Outstanding Unit Award with Valor.
Infection Control committee.
Established a new multidisciplinary weight loss surgery program. Performed over 100 laparoscopic weight loss operations. Recognized as a center of excellence by Air Force Headquarter.
 
Surgeon: July 2001 - July 2002
Active duty. 121st General Hospital. Major.
Chief of General Surgery.
Air Force Commendation Medal. Army Commendation Medal. Meritorious Service Medal.
Infection Control Committee.
 
 
 
 
Flight Surgeon at United States Air Force
September 19937 - June 1996
Active duty. Nellis Federal Hospital. Captain.
Deployed to the Middle East for Operation Southern Watch and Operation Vigilant Warrior. Aerospace Medicine physician, 561st Fighter Squadron. Medical Director, Military Public Health. Air Force Achievement Medal. Aerial Achievement Medal.
Active participation in flying operations of F-4, F-15, and F-16 fighter jets, C-130, AWACS, and Black Hawk helicopters.
Aerospace medicine, flight medicine, military public health, primary care medicine, family practice medicine, flight physicals, pediatric medicine, minor surgery.
 
 
 
 
   
 
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