Tom Paulson Email & Phone Number

Seattle

Oversight of Medical Review FunctionStrategic support of network and quality management

Responsibilities included oversight of all physician review and network medical director functions for the health plan in addition to physician leadership of clinical review and care management departments. Key accomplishments included; Leadership of nationally recognized EDHI project leading to 19% reduction in Medicare admissions and 20 % reduction in 30 day all cause readmissions over a three year period.Providing clinical leadership for implementation of a new Care Management… Show more Responsibilities included oversight of all physician review and network medical director functions for the health plan in addition to physician leadership of clinical review and care management departments. Key accomplishments included; Leadership of nationally recognized EDHI project leading to 19% reduction in Medicare admissions and 20 % reduction in 30 day all cause readmissions over a three year period.Providing clinical leadership for implementation of a new Care Management Information System.Supporting the enhancement of the Health plan medical management capabilities through expansion and integration of medical policy with benefit and payment policy apparatus.Selection and implementation of predictive modeling system to enhance case identification within care management and primary care medical home infrastructures. Show less

Oversight of health plan physician review functions and liaison with Review Services & Care Management departments and the physician group practice.-Assess, advise, and implement medical management improvement opportunities in the contracted network.-Partner with group practice leadership to support utilization and quality improvement and medical cost reduction.

Greater Seattle Area

Provided Medical Management consulting to area healthcare companies.key projects included: support for the assessment of care management information systems. and design and development of independent physician review function under ACA regulations.

Formulated and integrated medical policy with payment and reimbursement policy. Reviewed clinical matters and member /provider appeal resolutions for issues related to interpretation of medical policy and plan language definitions. Managed 5 full time and 11 part-time direct reports. Revised MD review process to identify "always E&I" policies. Gained efficiency in review and appeal process.Created multiple plan specific code pair edits in… Show more Formulated and integrated medical policy with payment and reimbursement policy. Reviewed clinical matters and member /provider appeal resolutions for issues related to interpretation of medical policy and plan language definitions. Managed 5 full time and 11 part-time direct reports. Revised MD review process to identify "always E&I" policies. Gained efficiency in review and appeal process.Created multiple plan specific code pair edits in "iCES" claim edit tool to increase auto adjudication of medical necessity issues. Created activity based accounting tool to measure return on assets for clinical review and to incorporate data into standard administrative value assessment for each medical policy.Led initiative to update utilization management strategy for Behavioral Health and Chemical Dependency services under Mental Health Parity.Led Chiropractic and CAM provider quality improvement and network restructuring initiative based on proprietary quality and billing profiling tool. Show less

Four-state, not for profit, Blue Shield payer.Responsibilities included oversight of care management functions and utilization management for Washington Plan, and support of clinician quality and efficiency performance measurement initiative.Designed and implemented medical management program for Medicare Advantage four state local PPO product; first multi-state product managed out of one plan (Regence of Oregon).Contributed to strategic formulation of "Regence Vitality"… Show more Four-state, not for profit, Blue Shield payer.Responsibilities included oversight of care management functions and utilization management for Washington Plan, and support of clinician quality and efficiency performance measurement initiative.Designed and implemented medical management program for Medicare Advantage four state local PPO product; first multi-state product managed out of one plan (Regence of Oregon).Contributed to strategic formulation of "Regence Vitality", an integrated outsourced wellness service positioned for "off the shelf" purchase by small employers interested in supplementing consumer directed healthcare products. Show less

of established, for profit, Medicare + Choice plan and commercial HMO carrier. Accountable for: Utilization management, appeals & grievance resolution, and disease management. Quality Oversight Liaison with medical groups.Repeatedly achieved 15 - 20% reduction in hospital bed-days for senior and commercial products in assigned groups that transitioned from capitation to fee-for-service during initial two years of transition.Formalized process to detect regional variances in… Show more of established, for profit, Medicare + Choice plan and commercial HMO carrier. Accountable for: Utilization management, appeals & grievance resolution, and disease management. Quality Oversight Liaison with medical groups.Repeatedly achieved 15 - 20% reduction in hospital bed-days for senior and commercial products in assigned groups that transitioned from capitation to fee-for-service during initial two years of transition.Formalized process to detect regional variances in cost of care and created business intelligence for purpose of improved contract negotiation strategies. Served as liaison among functional areas to implement best practices.Managed composite FFS network of 20,000 seniors and 28,000 commercial lives to 14% below state network average (1040 and 160 days PTMPY).Managed commercial bed-days for Washington state composite network to 9% below 2003 budget target.Created first quality bonus FFS contract for NW Medicare population. Demonstrated innovative SNF bed purchase option and Hospitalist service line contracts. Show less

for a start up HMO product sold as a Multiplan option with Great West Life PPO, POS, and indemnity plans. Responsible for utilization/medical management, quality management oversight and strategic input on network development. Developed credentialing system for proprietary Complementary/Alternative care provider network and a midwife/ birth center network to comply with Washington state mandate

Board of Directors (160-doctor multi-specialty clinic)Vice President of Medical Partners Northwest (a consortium of four area primary care groups and The Everett Clinic, providing contracting and case management services for global risk capitation accounts)Head of Family Medicine DepartmentSelected to serve on several successful strategic planning committees including "physician compensation reform."Created Urgent Care and Hospitalist service lines.Managed… Show more Board of Directors (160-doctor multi-specialty clinic)Vice President of Medical Partners Northwest (a consortium of four area primary care groups and The Everett Clinic, providing contracting and case management services for global risk capitation accounts)Head of Family Medicine DepartmentSelected to serve on several successful strategic planning committees including "physician compensation reform."Created Urgent Care and Hospitalist service lines.Managed multiple roles and responsibilities both in and out of this organization Show less

0.2 FTE) Provided medical quality oversight for two award winning long-term care facilities. Gave strategic and clinical input into formation of new joint venture "in hospital" transitional care unit. Liaison with referring physician groups and government / regulatory agencies.

Executive Mba, Healthcare Emphasis

Executive MBA program focused on application of Business Administration core functions to the Healthcare industry. A major emphasis.

Md, Medicine

Education record

Bs, Biology And Chemistry