Oversight of large clinical and non-clinical team divided between Population Health and Utilization Management while holding full budget responsibility. Accountable for providing short and long-term strategic goals for the team based on ongoing medical trends. A trusted thought leader in driving innovation, streamlining processes, and continuous improvement.➣ Consistently recognized by leadership for meeting or exceeding monthly, quarterly, and yearly KPIs.➣ Establishes, monitors, and achieves operational performance metric targets in collaboration with the Chief Medical Officer, Medical and Pharmacy Directors, and external vendors. ➣ Directs clinical operations, including care management and population health for the Senior Products division.➣ Develops strategy, coordinates, and implements a best-in-class, high-performing, high-morale health services organization with an emphasis on flexibility in a rapidly evolving marketplace. ➣ Maintains oversight for existing and the development of new clinical and administrative initiatives that impact medical costs that improve operational and financial performance and ensures a strong competitive position. ➣ Collaborates with Medical Directors performing medical management reviews for BCBST to ensure consistent, timely reviews and appeals.

Directed a six-person Commerical Clinical Pharmacy Specialist team dedicated to executing enterprise and departmental initiatives. Identified, documented, and quantified all CPS activities to capture productivity and to evaluate the effectiveness of core processes. Served as a primary resource for strategy, guidance, recommendations, and solutions. ➣ Developed and documented processes and workflows to support the annual review of 12,000 pharmacy prior authorizations, formulary exceptions, and appeals. ➣ Spearheaded departmental efforts to identify specific opportunities to enhance the Rx411 platform and content.

Led the oversight and accountability of the Utilization Management (UM) function for 125,000 Medicare Advantage members, which included prospective, appeal, and retrospective reviews of inpatient, ancillary, and pharmacy case types. Coordinated and managed both internal and external member education, consultation, problem resolution, and prevention. Conducted expert evaluation and consultation for legal, legislative inquiries, annual reviews, audits, and reaccreditations. ➣ Collaborated with the Chief Medical Officer to implement new programs such as concurrent reviews, medical rounds, readmissions, administrative approval, and length of stay guidelines with a subsequent decrease in the average length of stay and readmission rate for acute and post-acute facilities.➣ Monitored and enforced regulatory, accreditation, corporate, and compliance standards for approximately 38,000 calls, 10,000 faxes, and 192,000 authorizations annually.➣ Led the transformation and restructuring of 80 employees into two distinct teams, which represented geographic locations and multi-disciplinary duties.➣ Implemented and managed clinical vendor programs in accordance with Delegate Oversight and Corporate Compliance to meet member’s needs related to musculoskeletal, behavioral health, pharmacy, and high-tech imaging.

Provided strategic guidance, direction, and ongoing support for a team of 15-32 exempt and non-exempt employees. Led staff hiring, training, development, and performance management. Closely monitored the consistency, proficiency, and quality of both clinical and non-clinical staff to ensure highly-productive department operations.➣ Implemented clinical policies and procedures to comply with CMS, URAC, BCBST, and state standards and regulations.➣ Proactively addressed and resolved issues for internal customers, providers, and members professionally and discreetly. ➣ Conceptualized and executed creative strategies for reducing costs and overall medical spending by leveraging extensive data gathering and analysis of market trends.

Charged with researching and performing data analysis of quality concerns leveraging clinical experience, BCBST policies, and CMS guidelines. Presented written analysis of clinical risk/quality management concerns to the Medical Director, Corporate Medical Directors, the Chief Medical Officer, the Clinical Risk Management Committee, and Specialty Matched Reviewers.➣ Performed root cause analysis to identify, track, and resolve adverse events, including the development, implementation, and monitoring of corrective action plans.➣ Evaluated reports and referrals for clinical and quality management concerns for validity, severity, and trending. ➣ Promoted and maintained the quality of medical and clinical services for BCBST members.

Served as co-owner for a family-owned company that sold a wide variety of cars, trucks, and vans nationwide. Accountable for overseeing the day-to-day administrative, legal, and financial operations that included staff supervision, inventory management, accounts payable/receivable, and the company’s online presence. ➣ Conducted regular internal assessments and quality assurance reviews to evaluate and confirm compliance with regulations mandated by the State of Tennessee Motor Vehicle Commission.➣ Spearheaded customer strategies, delegated priorities, identified market trends, hired consultants and contractors, and helped drive the business for continued growth.

Promoted and tasked with coordinating grievance and appeal cases for the Medical Director and Physician reviewers. Negotiated out of network fees and presented quarterly reports to the Erlanger Health System Board of Directors. ➣ Established and implemented utilization management policies and procedures across all lines of business.➣ Audited and trained clinicians to ensure consistent knowledge and unity throughout the department, maintained strict department compliance with URAC and NCQA standards.