Manage healthcare and pharmaceutical utilization for 8 Medicare, 2 Medi-Cal, and 7 Commercial health plans.Develop and revise Clinical Criteria and policies and procedures for all lines of business.Present HICE reports, medical policies and other dashboards to the UM Committee.Collaborate in Joint Operating Committee (JOC) and various work groups with multiple health plans. Participate in CMS and state audits with partner health plans and respond to queries and corrective action plans.Provide UM determinations using multiple commercial health plan guidelines for Aetna, Anthem, Blue Shield of California, Cigna, Healthnet/Centene, and United Healthcare health plans.Provide UM determinations for Medicare Advantage plans using Medicare Local Coverage Determinations and National Coverage Determinations.

Managed a budget and the operations of five business units (50 FTEs) at an International Pharmacy Benefit Management (PBM) company including:- Clinical Guideline development with decision trees: - Pharmacy appeals and grievances;- a Quality/NCQA accreditation team; and - Formulary and Prior Authorization oversight teams that responded to 9 Medicare part D audits, and audits by multiple health plans, self insured employers and state agencies across the country. Led the efforts to achieve a three year NCQA PBM re-accreditation. Served on Pharmacy & Therapeutics committee, and UM Oversight and Quality committees. Provided clinical oversight of contracted physician reviewers, including Inter-rater reliability testing using National Comprehensive Cancer Network (NCCN) criteria.Collaborated across multiple business units to develop a Formulary Exception process.

Managed health care utilization for a Medicare and Medicaid health plan. Provided medical oversight of UM/QI/case management functions. Developed Health Plan policies and criteria which were automated into an MCG client module.Served on Pharmacy and Therapeutics Committee, Medical Services UM and Quality Committee, Provider Credentialing and Peer Review committees. Met with providers and hospitals on utilization and health plan policies and procedures. Participated in audits with state agencies (DMHC and DHCS). Provided clinical oversight of physician reviewers.Co-Chair of the Clinical Review Team for Whole Person Wellness, a San Diego county initiative.

Researched medical literature to develop and update evidence-based clinical guidelines including pharmaceutical therapies, optimal recovery care guidelines for inpatient care, outpatient procedures and diagnostic tests, specialty referral management, high cost drugs, and emerging healthcare technologies. Guidelines are licensed as a software product by over 2,200 clients which include 7 of the 8 largest health plans and over 1,200 provider organizations including hospital systems, IPAs, and accountable care organizations.Reviewed Agency for Healthcare Research and Quality (AHRQ) technology assessments, Food and Drug Administration (FDA) sources, the Cochrane library of systematic reviews/meta-analysis and National Comprehensive Cancer Network (NCCN) guidelines as references to support clinical guidelines.Drafted responses and provider queries for the Chief Medical Officer/Editor in Chief.Reviewed and incorporated input from specialist peer reviewer of the criteria.

Managed health care and pharmaceutical utilization in a large capitated IPA. Provided clinical and managed care leadership to regional, primary care, and specialty physician advisory councils.Served on Quality Committee and Regional UM Committee with participating providers.Implemented a review process for spine surgery with projected annual savings of $500,000.