Experience

100 Voices of Hope IU Simon Cancer Center

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

• Clinical Oncology Coordinator

  • Jul 2019 - Present



Evolent Health

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

• Senior Director Market Operations

  • Jan 2018 - Jan 2019



Superior Health Plan Inc

• Vice President Medical Management

  • Oct 2015 - Mar 2017

  Direct and coordinate activities of the department and aid the chief officerof the health plan and appropriate corporate staff in formulating andadministering organizational and departmental policies. Reviewanalyses of activities, costs, operations and forecast data to determinedepartment progress toward stated goals and objectives. Serve as amember of management committees on special studies. Administerand ensure compliance with National Committee on Quality Assurance(NCQA) and/or Joint Commission on Accreditation of HealthcareOrganization (JACHO) standards as determined for accreditationof the health plan. Participate in, attend and plan/coordinate staff,departmental, committee, sub-committee, community, State and otheractivities, meetings and seminars.



PruittHealth Corporation

• Vice President of Care Integration

  • Apr 2013 - Oct 2015

  Accountable for oversight of the planning and execution of Care Management activities, including defining operational priorities, overseeing process and system implementations, monitoring Key Performance Indicators (KPIs), measuring results, allocating resources and building strategic partnerships to improve care coordination and transitions of care within various PruittHealth service lines (Health Care Centers (HCC), Home Care, Hospice, Home Infusion and Durable Medical Equipment (DME)). Responsible for managing system-wide, leading practice standardization as it relates to patient referral, patient intake, payer authorization and care management functions/processes. Promotes solutions that accelerate the dissemination of successful leading practice and creating organizational alignment.



Anthem, Inc.

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

• Program Director, Medical Management, Anthem National Accounts

  • 2005 - Apr 2013

  •Responsible for coordinating the strategic direction, overall compliance, and operational readiness for Utilization Management and Case Management across the enterprise. •Participate in or lead committees that include pre-certification claim review, cost of care, medical policy development and implementation, and account-specific benefit development. •Lead the Medical Management Integration Committee in the development of claim suspension guidelines and procedures for four different claim platforms. •Chair the Medical Management Committee to establish and implement a standardized pre-certification list for all of National Accounts, and collaboratively work with the Implementation teams to ensure accurate distribution and compliance. •Oversight of any new Quality Improvement programs and or initiatives. •Overall activity oversight of 200 + staff members.•Lead representative for Utilization Management on the National Account Approval Process that reviews and approves any non-standard benefit or pre-certification requests by accounts. •Function as the primary subject matter expert for National Account Medical Operations and also lend that expertise to Commercial business given our cross-functionality and shared services model.

• Manager, National Accounts Medical Review

  • Mar 2005 - Nov 2006

  •Primary responsibility of oversight of the medical claim review area. •Responsible for medical necessity determinations for 2.4 million members on the NASCO claim platform. •Responsible for the oversight of 21 Registered Nurses and two ancillary staff members, overall quality improvement and compliance activities, including a successful URAC review in 2006, and support of the National Account Eligibility Unit. •Led the department in the successful completion of the medical management system migration in July of 2006 with no member or provider disruption. •This migration included the automation and standardization of denial letters that met the requirements of all 50 states’ Departments of Insurance.•Managed the Six Sigma directed effort to standardize workflows between the clinical and claims processing areas, thereby decreasing processing time from an average of 31 calendar days to an average of 14 calendar days.



Indiana Wesleyan University

• United States
• Higher Education
• 700 & Above Employee

• Adjunct Faculty

  • 2008 - 2008

  Taught Business Law classes to undergraduate students in a part-time role.



Anthem

• Management Consulting
• 1 - 100 Employee

• Regional Coordinator, Medical Policy

  • Dec 2003 - Mar 2005

  •Provided education to clinical staff and guidance regarding implementation to claim staff. •Led the Central Region Committee for standardization following the Anthem-WellPoint merger and was successful in implementing 347 new medical policies and clinical guidelines in a nine month period. •This effort led to consistent medical decision-making for the newly formed enterprise and decreasing potential legal exposure from inconsistent clinical decision making.



Community Hospitals of Indianapolis

• United States
• Medical Practices
• 1 - 100 Employee

• Staff Nurse, Oncology/Renal

  • 2002 - 2003

  •Responsibility of providing direct patient care to highly compromised patients in an inpatient setting. •Responsibilities included charge nurse and process improvement activities.



CIGNA Healthcare

• Hospitals and Health Care
• 700 & Above Employee

• Contract Consultant

  • 2000 - 2002

  •Facility and Ancillary Contracting with the responsibility of provider contract negotiations. •A key success was the establishment of a network of urgent care centers as part of an effort to reduce emergency room utilization and costs. •Contracted with 28 different urgent care facilities and set up a utilization management process of re-directing care where appropriate. •This effort also included a re-design of the copayment structures for over 125 accounts to incentivize members in accessing a more appropriate level of care, saving the company $322,000 in the first year of implementation.



Cooperative Managed Care Services

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

• Supervisor, Case Management

  • Jul 1999 - May 2000

  Direct supervision of 5 case managers for local TPA servicing full-risk PHO Networks.



Maxicare of Indiana

• Director, Provider Relations and Network Development

  • Jun 1997 - Jul 1999



USAF

• Guinea
• International Trade and Development

• Computer Operations

  • 1981 - 1985

  Worked at AFGWC in Computer Operations (System1/4).