My responsibilities at NGS, the nation’s largest Medicare Carrier, include working and meeting with CMS officials (both on a regional and on a national level), technology assessment (including investigational device exemptions), evaluation of medical treatments, developing and implementing Medicare policies over a ten state area, medical review, physician profiling, pricing services, fraud and abuse detection/prevention, claims coding and rebundling charges, working with other Medicare medical directors regionally and nationally on Medicare issues, data analysis, working with the Department of Justice, FBI, & Office of the Inspector General (OIG), attending the Provider Outreach and Education (POE) Advisory Group meetings, meeting with leaders of the state specialty medical societies, meeting with the State Medical Society, and educating all J6 and JK providers about Medicare.

My responsibilities at WPS, the nation’s largest Medicare Carrier, include working and meeting with CMS officials (both on a regional and on a national level), technology assessment (including investigational device exemptions), evaluation of medical treatments, developing and implementing Medicare policies over a eight state area (including Iowa, Kansas, Missouri, and Nebraska), writing medical articles for the monthly Medicare B Communiqué, coordinating with the regional Medicare A fiscal intermediaries, medical review, physician profiling, pricing services, fraud and abuse detection/prevention, claims coding and rebundling charges, working with other carrier medical directors regionally and nationally on Medicare issues, data analysis, working with the Department of Justice, FBI, & Office of the Inspector General (OIG), co-chairing the Carrier Advisory Committee meetings, attending the Provider Outreach and Education (POE) Advisory Group meetings, meeting with leaders of the state specialty medical societies, meeting with the State Medical Society, and educating all Illinois/Minnesota providers about Medicare. November 2007 I also became the Medicare Part A (fiscal intermediary) medical director for Mutual of Omaha/WPS in all states except New York. This position for the largest Fiscal Intermediary includes the Part A equivalent of all the Medicare B duties, except on a national scale.

My responsibilities at this mixed model HMO included preparing for NCQA accreditation, credentialing, physician profiling, utilization review, case management, quality improvement, negotiating contracts with new and existing providers, initiating disease management programs, negotiating settlements on large claims with non-providers, HEDIS, assisting the marketing department and network management departments develop new networks, chairing committees, helping IPA medical directors reduce medical loss ratios, acting as the Vice-President/General Manager in his absence, coding and rebundling of charges, selecting new drugs for our national formulary, claims review, evaluation of medical treatments, financial analysis, presenting to the State of Illinois legislative committees, meeting with political officials, and evaluation of new technology.