➤ Ensuring ongoing development/implementation of policies that guide and support provision of medical staff services.➤ Serving as the primary liaison between the Administration and medical staff, working to achieve quality outcomes.➤ Developing and implementing medical management strategic plans for the market, while aligning with matrix partners.➤ Stabilizing, improving, and educating Primary Care Physician & Specialty networks, and monitoring practice patterns.➤ Recommending corrective actions as needed to ensure that the care provided meets the standards for acceptable care.➤ Ensuring medical decisions are rendered by qualified personnel, not influenced by fiscal or administrative concerns.➤ Participating in quality processes such as audits, inter-rater reliability, clinical reviews, as well as quality projects.➤ Focusing on service and cost optimization, including evaluating and implementing new technologies and treatments.➤ Maintaining a working knowledge of applicable national, State, local laws and regulatory requirements affecting staff.➤ Achieving internal customer satisfaction and accreditation compliance goals by assuring timely turnaround of reviews.➤ Serving as a mentor and coach to other Medical Directors and colleagues around QA and performance improvement.➤ Attending or chairing committees, such as Credentialing, P&T, and others as directed by the Chief Medical Officer.➤ Interacting with network and group providers and Medical Managers regarding practices and resource management.➤ Conducting retrospective reviews of claims and appeals, and resolving grievances related to medical quality of care.➤ Monitoring services through continuum among hospitals, skilled nursing facilities, home care to ensure cost-efficiency.

➤ Directed utilization management of 59K STAR+PLUS (Medicaid) and STAR+PLUS Dual (Medicare & Medicaid).➤ Effectively supported Tarrant and Hidalgo Counties and North-East TX, balancing customer and business needs.➤ Provided clinical insight to the organization through peer review, benefit review, consultation, and service to customers.➤ Served as a clinical educator regarding utilization management, case management, network, contracting, and pharmacy.➤ Performed benefit-driven medical necessity reviews for coverage and claims resolution, using best practice principles.➤ Strategically oversaw a team of Nurses and Social Workers who managed member utilization and disease management.➤ Applied continuous process improvement strategies to enhance case management in acute inpatient admission.➤ Successfully leveraged benefit plan information, applicable Federal and State regulations, as well as clinical guidelines.➤ Directed medical management functions for programs including QA, while handling pharmacy and general appeals.➤ Handled population health control via various disease management programs, as well as Hospice service development.➤ Improved clinical outcomes through interactions with health care professionals, while serving as a member advocate.➤ Participated in all levels of the Appeals process as allowed by Regulatory agencies and accreditation organizations.➤ Contributed to coverage guideline development, and creation of medical management projects, initiatives, committees.➤ Investigated and responded to client or regulatory questions to resolve issues, and provided support to leadership staff.

Premier Physician Group – 06/2020 to CurrentH.E.B. Hospital, Bedford, TX Team Health-Methodist, Mansfield – 12/2011 to 11/2021 ➤ Successfully providing administration, denial management, and case management with LOS and CDI.➤ Working for 2 companies simultaneously, 1 focused on clinical and the other the business, including administration.➤ Restricting scope of practice to exclusively care for hospitalized patients, providing advanced primary/specialty care.➤ Working closely with the patients to ensure that tests and routine procedures are completed in a more timely manner.➤ Conducting patient health assessments and creating strategies to manage and improve their health and well-being.➤ Introducing habits that promote health, while responding to questions and concerns and discussing proper self-care.➤ Supporting and administering admissions, consults, rounding, and discharges, as well as ordering tests and treatments.

➤ Provided direct oversight to 4 Nurse Practitioners, and provided feedback on performance and areas for improvement.➤ Executed and renewed the collaborative agreement, as required, and remained available during clinical activities.➤ Conducted quality reviews of patient charts on a periodic basis based on State licensing and supervision requirements.➤ Proactively considered the relative costs and benefits of potential actions to ensure most appropriate one was chosen.➤ Leveraged knowledge of symptoms, treatment alternatives, drug properties/interactions, and preventative measures.

➤ Primary Care Physician – Texas Health Physicians Group, Colleyville, TX – 2009 to 2011➤ Hospitalist Program Director & PCP – Waldo County General Hospital, Belfast, ME – 2006 to 2009➤ Staff Physician – White County Hospital, Sparta, TN – 2005 to 2006