Stacie Nelson Email and Phone Number

Lead business and operational efforts to develop and maintain coverage policy process that support benefit implementation for UCare’s products. Manage specific projects such as Preventive Benefit related to the Affordable Care Act. Collaborates with Claims Operations and other teams to assure benefit intent. Manage performance of Coverage Policy Team.

Projects: Healthcare, managed care, medical policy, reimbursement consulting (specialty pharmacy and oncology), medical writing and editing, nursing student mentoring and advising.

-Director of Payment Integrity: 9/2015-9/2016 Leadership of 42 clinical and compliance professionals including Clinical Retrospective Claims, Coding, and Coding Appeals Teams, budget management (57.5M)Co-led project to develop reimbursement policies posted on Blue Cross website resulting in transparency and clarity for Blue Cross providers and improved consistency of claims payment for members.Directed major change initiative of new payment platform for coding set-up and claims payment; development of new committee processes, and increased rigor of approval process resulting in enhanced documentation of processes, decisions, and meeting outcomes for regulatory compliance-Director, Medical Policy, Compliance, Peer Review (2010 – 2015)Budget management (2M), and leadership of 15 professionals.Directed end-to-end medical and behavioral health policy and coverage determination process including policy topic management and tracking, formal committee management, internal, external communication and training.Led medical evidence evaluation and research support process, preparation of evidence briefs on new medical technologies for use by Medical Leadership, Public Relations, and Executives.Participated in corporate initiatives such as medical fraud and medical expense trend management for commercial, government, and pharmacy management.Collaborated with Corporate Compliance to prepare division for state, federal, and accreditation audits.Spearheaded design, development, and implementation of regulatory policies throughout departments.Led physician case review coordination process as a component of utilization management and appeals process, managed specialist physician contracting process and budget for clinical appeals.Responsible for executing the Preventive benefit component of the Affordable Care Act legislation organization-wide.

Researched Medicare, Medicaid, and commercial payer policy, payment, and coding rules for Medtronic neuromodulation therapies. Advised cross-divisional teams on reimbursement strategy and coverage options. Provided guidance on clinical study design, including cost effectiveness and budgeting, and informed Product Development on payer reimbursement policy and coverage options. Strategized with cross-functional teams on a variety of projects regarding pain therapies and drug treatment options. Developed global reimbursement plan in U.S., Europe, and Asia Pacific regions in conjunction with global therapy business plan with goal of obtaining postive reimbursement upon product launch, Trained Sales and Field Reimbursement Staff on best practices and compliance.Promoted Medtronic therapies to physicians and physician specialty societies.Completed Pain Therapy Physician Sales Training.

Performance management and leadership of 10 professionals, budget management, clinical project management.Managed all facets of medical policy and technology assessment process including: research support, leading committees of physicians, evaluating quality of clinical evidence that informed coverage determination process, communication, and training for Registered Nurses and stakeholders. Led staff in preparation of defensible research briefs and medical policy documents.Managed committees of physician experts who provided input into medical policy process, and strategic network issues. Conducted provider satisfaction survey.Maintained departmental regulatory and accreditation compliance for the Minnesota Department of Health and National Committee for Quality Assurance (NCQA). Recognition as member of Medica Foundation Grant Evaluation Committee, statewide committee for cancer clinical trials policy, and winner of Medica Cornerstone Award (team honor) for new medical technology evaluation process redesign.