Experience

Neighborhood Health Plan of Rhode Island

• Insurance
• 300 - 400 Employee

• Interim Director Of Case Management

  • Jun 2019 - Dec 2019

  Smithfield, Rhode Island, United States Selected by executive leadership to assume interim Director Of Case Management duties for six months. --the focus was ensuring compliance with regulatory standards and contract oversight.

• Director of Utilization Management and Clinical Medical Policy

  • Mar 2014 - Jun 2019

  United States • Implemented a new medical necessity review tool resulting in cost savings • Created a Transitions of Care team to support the Medicare and Medicaid duals population • Managed and provided oversight of a radiology advanced imaging contract and renegotiated this contract • Achieved 100% compliance to National Committee for Quality Assurance (NCQA) with Utilization Management standards every year since assuming responsibility (2012 – 2019) • Managed benefit and utilization… Show more • Implemented a new medical necessity review tool resulting in cost savings • Created a Transitions of Care team to support the Medicare and Medicaid duals population • Managed and provided oversight of a radiology advanced imaging contract and renegotiated this contract • Achieved 100% compliance to National Committee for Quality Assurance (NCQA) with Utilization Management standards every year since assuming responsibility (2012 – 2019) • Managed benefit and utilization processes for Medicaid, Commercial and Medicaid-Medicare dual eligible members • Achieved subject matter expertise of regulatory standards related to utilization management • Achieved experience with CPT, HCPC, and ICD codes

• Senior Manager of Utilization Management and Clinical Medical Policy,

  • Feb 2013 - Feb 2014

  Providence, Rhode Island, United States • Developed, directed and monitored all Utilization Management and medical policy programs that served approximately 100,000 Neighborhood members • Ensured compliance with all regulatory standards (CMS, DHS, DOH, NCQA) • Contract oversight of radiology and medical criteria vendors • Developed and monitored utilization management process for existing and new lines of business • Prepared and analyzed reports to identify over and under-utilization rates • Monitored utilization… Show more • Developed, directed and monitored all Utilization Management and medical policy programs that served approximately 100,000 Neighborhood members • Ensured compliance with all regulatory standards (CMS, DHS, DOH, NCQA) • Contract oversight of radiology and medical criteria vendors • Developed and monitored utilization management process for existing and new lines of business • Prepared and analyzed reports to identify over and under-utilization rates • Monitored utilization decision-making to include overturned appeals and physician decision trends

• Manager of Utilization Management and Clinical Medical Policy

  • Mar 2012 - Jan 2013

  Providence, Rhode Island, United States

• Manager of Case and Disease Management,

  • Jul 2010 - Feb 2012

  Providence, Rhode Island, United States

• Team Lead, Utilization Management and Clinical Medical Policy

  • Feb 2007 - Jun 2010

  Providence, Rhode Island, United States • Assisted with development and revisions of policies and procedures, and assisted in developing and design of new programs • Ensured compliance with regulatory requirements as it related to denials and appeals • Reviewed denial and appeal letters and monitored for compliance to timelines • Assessed staffs’ performance and was accountable for completing annual performance reviews • Communicated with external customers (providers, vendors) to clarify benefits and/or the medical… Show more • Assisted with development and revisions of policies and procedures, and assisted in developing and design of new programs • Ensured compliance with regulatory requirements as it related to denials and appeals • Reviewed denial and appeal letters and monitored for compliance to timelines • Assessed staffs’ performance and was accountable for completing annual performance reviews • Communicated with external customers (providers, vendors) to clarify benefits and/or the medical review process • Assisted in coordinating and/or participating in the orientations of new staff • Collaborated with the physician advisor when cases did not meet established criteria or guidelines



Beacon Health Strategies

• United States
• Hospitals and Health Care
• 100 - 200 Employee

• Clinical Case Manager

  • Dec 2005 - Jan 2007

  Providence, Rhode Island, United States Managed the behavioral health needs of members who were in the Medicaid and Medicare dual eligible line of business