Experience

Post Acute Analytics

• United States
• Hospitals and Health Care
• 1 - 100 Employee

• Chief Medical Officer, Post Acute Analytics

  • Mar 2022 - Present



Somatus

• United States
• Hospitals and Health Care
• 400 - 500 Employee

• Vice President, Utilization Management

  • 2020 - 2021

  Charlotte, North Carolina, United States



naviHealth

• United States
• Hospitals and Health Care
• 700 & Above Employee

• Executive Medical Director

  • Nov 2018 - Dec 2020

• Executive Medical Director

  • Nov 2018 - Dec 2020

  Brentwood, TN Promoted to manage enormous program growth. Tripled the size of the medical department and grew the team to 50 medical directors nationwide with 2 quality analysts, to manage over 3.5 million Medicare Advantage lives. Report to the CMO and oversee account management for the 2 largest Medicare Advantage Care plan clients.

• Senior Medical Director

  • Nov 2016 - Nov 2018

  Brentwood, TN Report to the Chief Clinical Officer. Promoted into role to ensure that quality initiatives for the corporate clinical model are standardized and patient focused. Manage a remote team of 8 medical directors (out of 16) in TX, NY, MD, CO, CA, NC and SC. Concentrate on patient outcomes in support of plan partners, including one of the largest health plans in the country and multiple small, independent regional plans in 6 states. Serve as the front-facing physician for health plan partners and… Show more Report to the Chief Clinical Officer. Promoted into role to ensure that quality initiatives for the corporate clinical model are standardized and patient focused. Manage a remote team of 8 medical directors (out of 16) in TX, NY, MD, CO, CA, NC and SC. Concentrate on patient outcomes in support of plan partners, including one of the largest health plans in the country and multiple small, independent regional plans in 6 states. Serve as the front-facing physician for health plan partners and manage the complicated politics of these relationships. • Developed the first formal physician onboarding program to ensure a clear understanding of CMS Guidelines and consistent passing of CMS Guidelines and IRR Reliability exams. • Launched the new on-boarding program in Spring 2017; includes training, shadowing, case management and use of predictive analytics for acute care patients, with on-site and online training modules. • Coach 25 field care coordinators on standards of care, transition of care barriers, and positive outcomes. • Partnered with the network management team to identify variations in post-acute care at skilled nursing facilities and shared critical data with health plan partners and hospitals to aid in network optimization. • Conduct quarterly retrospective quality audits to ensure appropriate determinations are being made and appropriate CMS guidelines are followed. • Meet monthly with health plan clients to demonstrate the value and benefit of the naviHealth clinical model; provide metrics that show improvements in length of stay, quality outcomes and re-admissions. naviHealth Results: • Cut Skilled Nursing Facilities (SNF) length of stay >40% over 3 years with no decrease in quality outcomes or increase in re-admissions. • Reduced re-admissions from SNF and home healthcare. • Maintain a QIO appeal uphold rate of over 80%.



naviHealth

• United States
• Hospitals and Health Care
• 700 & Above Employee

• Medical Director- North Carolina/Southeast Region

  • 2014 - 2016

  Brentwood, TN -Reported to CMO. Oversaw a managed care team of 20 pre-service care coordinators and SICCs in authorizing and reviewing Medicare Advantage member cases across the spectrum of post-acute settings (SNF, IRF, and LTAC). • Mentored new medical directors, and educated staff nurses and therapists on medical topics and CMS Guidelines to guide post-acute coverage decisions. • Performed outreach to acute and post-acute practicing physicians and major care chains to educate case managers… Show more -Reported to CMO. Oversaw a managed care team of 20 pre-service care coordinators and SICCs in authorizing and reviewing Medicare Advantage member cases across the spectrum of post-acute settings (SNF, IRF, and LTAC). • Mentored new medical directors, and educated staff nurses and therapists on medical topics and CMS Guidelines to guide post-acute coverage decisions. • Performed outreach to acute and post-acute practicing physicians and major care chains to educate case managers, physician advisors and medical directors on the ways naviHealth could improve patient outcomes. • Provided onsite and remote consultant support to hospital partners participating in the CMS Bundled Payments for Care Improvement (BPCI) program in Florida to help them optimize their networks. • Repeatedly proved the value of naviHealth services to its growing network of plan partners to generate increased contractual arrangements with multiple health plans. Show less



The Carolinas Emergency Group

• Emergency Medicine Physician

  • 2012 - 2016

  Waxhaw, NC



Optum/Executive Health Resources

• Government Appeals Physician Advisor

  • 2012 - 2014

  Newtown Square, PA -EHR provides medical necessity compliance and denials management solutions through its physician advisors to hospitals and health systems in the U.S. • Served as an appeals expert and client advocate in over 300 appeals of fee-for-service Medicare cases denied or downgraded by government contractors. • Authored legal memoranda and appeal letters on behalf of client hospitals. • Represented client hospitals to the Administrative Law Judge for the Office of Medicare Hearings and… Show more -EHR provides medical necessity compliance and denials management solutions through its physician advisors to hospitals and health systems in the U.S. • Served as an appeals expert and client advocate in over 300 appeals of fee-for-service Medicare cases denied or downgraded by government contractors. • Authored legal memoranda and appeal letters on behalf of client hospitals. • Represented client hospitals to the Administrative Law Judge for the Office of Medicare Hearings and Appeals. • Reviewed +/- 100 case records to determine the medical necessity for inpatient acute care, psychiatric, and rehabilitation admissions. • Conferred with representatives of client hospitals regarding the strength of appeals. • Reviewed approximately 50 outpatient specialty denials of coverage by governmental contractors. • Developed and wrote 8+ new medical arguments for specific conditions. Show less



Piedmont Emergency Medical Associates, now USACS

• Emergency Medicine Physician

  • 2002 - 2012

  Charlotte, North Carolina Area



EMP, Ltd

• MD

  • Aug 2001 - Sep 2002

  Elizabeth City, NC