Experience

Aspire Health

• United States
• Insurance
• 1 - 100 Employee

• Director Utilization Management

  • Sep 2021 - Present

  Operational oversight and performance of prior authorization, utilization review practices, and correspondence to ensure compliance with regulatory, contractual, and accreditation requirements. Leads planning and growth development to meet current and future organizational needs. Works collaboratively with key stakeholders such as delegates to ensure effectiveness of all integrates functions such as customer services, provider services, pharmacy benefits management, member and provider… Show more Operational oversight and performance of prior authorization, utilization review practices, and correspondence to ensure compliance with regulatory, contractual, and accreditation requirements. Leads planning and growth development to meet current and future organizational needs. Works collaboratively with key stakeholders such as delegates to ensure effectiveness of all integrates functions such as customer services, provider services, pharmacy benefits management, member and provider satisfaction.

• Director Utilization Management

  • Sep 2021 - Present

  Operational oversight and performance of prior authorization, utilization review practices, and correspondence to ensure compliance with regulatory, contractual, and accreditation requirements. Leads planning and growth development to meet current and future organizational needs. Works collaboratively with key stakeholders such as delegates to ensure effectiveness of all integrates functions such as customer services, provider services, pharmacy benefits management, member and provider… Show more Operational oversight and performance of prior authorization, utilization review practices, and correspondence to ensure compliance with regulatory, contractual, and accreditation requirements. Leads planning and growth development to meet current and future organizational needs. Works collaboratively with key stakeholders such as delegates to ensure effectiveness of all integrates functions such as customer services, provider services, pharmacy benefits management, member and provider satisfaction.



Sutter Medical and Market Network

• Sacramento, California Area

• Director, Utilization Management

  • Aug 2016 - Present

  The Sutter Medical Network is a network of medical groups and Sutter Health that integrates the aspects of the care delivery system in order to improve the quality, service, and affordability of health care services. The purpose of the Sutter Medical Network, working in partnership with the overall Sutter Health network, is to provide consistently superb and affordable health care – where, when and how patients want it. The Sutter Medical Network Utilization Management Director provides… Show more The Sutter Medical Network is a network of medical groups and Sutter Health that integrates the aspects of the care delivery system in order to improve the quality, service, and affordability of health care services. The purpose of the Sutter Medical Network, working in partnership with the overall Sutter Health network, is to provide consistently superb and affordable health care – where, when and how patients want it. The Sutter Medical Network Utilization Management Director provides administrative leadership for the implementation of the Sutter Medical Network Utilization Management Program to ensure that Sutter patients have access to the most appropriate and cost efficient healthcare services. Working directly with, and at Sutter Medical Network member sites, this position serves as the single point of contact for assuring support services are provided, identifies priorities and resolves issues for physician organizations in regards to Utilization Management. This position assures effective coordination with other SMN programs, Network-wide Committees/Work Groups, Sutter Health Support Services functions and Sutter Physician Services. The SMN Director of UM: • Works with physician organizations to implement the work plans and standards developed in the SMN Utilization Management Committees and its sub-committees • Establishes specific work plan implementation schedules and time lines. • Aligns Sutter Medical Network priorities with other priorities unique to the physician organizations. • Provides periodic status update reports to the different Sutter Medical Network Committees/Work Groups and to the Sutter Medical Network Executive Committee, including identification of barriers to implementation and recommendations for problem resolution. • Helps assure that Committee/Work Group learning's and experience are built into the next round of planning for the Sutter Medical Network. Show less The Sutter Medical Network is a network of medical groups and Sutter Health that integrates the aspects of the care delivery system in order to improve the quality, service, and affordability of health care services. The purpose of the Sutter Medical Network, working in partnership with the overall Sutter Health network, is to provide consistently superb and affordable health care – where, when and how patients want it. The Sutter Medical Network Utilization Management Director provides… Show more The Sutter Medical Network is a network of medical groups and Sutter Health that integrates the aspects of the care delivery system in order to improve the quality, service, and affordability of health care services. The purpose of the Sutter Medical Network, working in partnership with the overall Sutter Health network, is to provide consistently superb and affordable health care – where, when and how patients want it. The Sutter Medical Network Utilization Management Director provides administrative leadership for the implementation of the Sutter Medical Network Utilization Management Program to ensure that Sutter patients have access to the most appropriate and cost efficient healthcare services. Working directly with, and at Sutter Medical Network member sites, this position serves as the single point of contact for assuring support services are provided, identifies priorities and resolves issues for physician organizations in regards to Utilization Management. This position assures effective coordination with other SMN programs, Network-wide Committees/Work Groups, Sutter Health Support Services functions and Sutter Physician Services. The SMN Director of UM: • Works with physician organizations to implement the work plans and standards developed in the SMN Utilization Management Committees and its sub-committees • Establishes specific work plan implementation schedules and time lines. • Aligns Sutter Medical Network priorities with other priorities unique to the physician organizations. • Provides periodic status update reports to the different Sutter Medical Network Committees/Work Groups and to the Sutter Medical Network Executive Committee, including identification of barriers to implementation and recommendations for problem resolution. • Helps assure that Committee/Work Group learning's and experience are built into the next round of planning for the Sutter Medical Network. Show less



River City Medical Group

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

• Senior Director Utilization Management and Case Management

  • Dec 2014 - Aug 2016

  Directs and improves the efficiencies of the utilization management of resources for participating provider networks while developing systems and processes to ensure efficient and effective provision of utilization and care management to the provider network. Creating a vision for how to serve the Managed Medi-Cal population and leveraging both from inpatient and outpatient perspectives. Directs activities related to medical review while monitoring the timeliness and accuracy of utilization… Show more Directs and improves the efficiencies of the utilization management of resources for participating provider networks while developing systems and processes to ensure efficient and effective provision of utilization and care management to the provider network. Creating a vision for how to serve the Managed Medi-Cal population and leveraging both from inpatient and outpatient perspectives. Directs activities related to medical review while monitoring the timeliness and accuracy of utilization management authorizations, data, and reporting. Leads utilization management activities including design and implementation of the programs that integrates with quality management. Integrates utilization and care management with both medical management and non-medical management departments (e.g. Customer Connections, Provider Services, Network Management, Claims, IT, etc.) Proactively identifies best practice methodologies and establishes training programs for utilization and care management and integrates activities with population health. Designs, leads, executes, and continuously improves special utilization management projects, initiatives, and tools that support partners in a scalable manner. Ensures compliance to conform with health plan, State and Federal requirements. Enhances relationships with providers, facilities, plan sponsors, clients, regulatory agencies, and partners. Show less Directs and improves the efficiencies of the utilization management of resources for participating provider networks while developing systems and processes to ensure efficient and effective provision of utilization and care management to the provider network. Creating a vision for how to serve the Managed Medi-Cal population and leveraging both from inpatient and outpatient perspectives. Directs activities related to medical review while monitoring the timeliness and accuracy of utilization… Show more Directs and improves the efficiencies of the utilization management of resources for participating provider networks while developing systems and processes to ensure efficient and effective provision of utilization and care management to the provider network. Creating a vision for how to serve the Managed Medi-Cal population and leveraging both from inpatient and outpatient perspectives. Directs activities related to medical review while monitoring the timeliness and accuracy of utilization management authorizations, data, and reporting. Leads utilization management activities including design and implementation of the programs that integrates with quality management. Integrates utilization and care management with both medical management and non-medical management departments (e.g. Customer Connections, Provider Services, Network Management, Claims, IT, etc.) Proactively identifies best practice methodologies and establishes training programs for utilization and care management and integrates activities with population health. Designs, leads, executes, and continuously improves special utilization management projects, initiatives, and tools that support partners in a scalable manner. Ensures compliance to conform with health plan, State and Federal requirements. Enhances relationships with providers, facilities, plan sponsors, clients, regulatory agencies, and partners. Show less



Evolent

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

• Managing Director, Utilization Management

  • Jun 2013 - Jun 2014

  Monitors the utilization management of resources of client network while developing systems and processes for the provider network. DIrects activities related to medical review while monitoring the timeliness and accuracy of utilization management data and reporting. Lead utilization management activities including design and implementation that integrates with quality management. Proactively identify best practice methodologies and training programs for utilization management and integration… Show more Monitors the utilization management of resources of client network while developing systems and processes for the provider network. DIrects activities related to medical review while monitoring the timeliness and accuracy of utilization management data and reporting. Lead utilization management activities including design and implementation that integrates with quality management. Proactively identify best practice methodologies and training programs for utilization management and integration with population health. Design, lead, execute, and continuously improve special utilization management projects, initiatives, and tools that support partners in a scalable manner. Enhance relationships with providers, facilities, plan sponsors, clients, regulatory agencies, and partners. Monitors member and provider satisfaction survey results and ensuring continuous quality improvement Show less Monitors the utilization management of resources of client network while developing systems and processes for the provider network. DIrects activities related to medical review while monitoring the timeliness and accuracy of utilization management data and reporting. Lead utilization management activities including design and implementation that integrates with quality management. Proactively identify best practice methodologies and training programs for utilization management and integration… Show more Monitors the utilization management of resources of client network while developing systems and processes for the provider network. DIrects activities related to medical review while monitoring the timeliness and accuracy of utilization management data and reporting. Lead utilization management activities including design and implementation that integrates with quality management. Proactively identify best practice methodologies and training programs for utilization management and integration with population health. Design, lead, execute, and continuously improve special utilization management projects, initiatives, and tools that support partners in a scalable manner. Enhance relationships with providers, facilities, plan sponsors, clients, regulatory agencies, and partners. Monitors member and provider satisfaction survey results and ensuring continuous quality improvement Show less



Health Net

• United States
• Insurance
• 700 & Above Employee

• Director, Decision Power Health and Wellness

  • Jun 2003 - Mar 2013

  Directed and led national health and wellness programs including integration between internal and external programs, client clinics, vendors and data platforms. Responsible for the disease management and wellness programs that support NCQA accreditation on a regional and national basis. Directs and oversees wellness health coaching program as well as integration with all vendors, departments, and programs at the plan, employer, physician, and medical group level. Directs the worksite… Show more Directed and led national health and wellness programs including integration between internal and external programs, client clinics, vendors and data platforms. Responsible for the disease management and wellness programs that support NCQA accreditation on a regional and national basis. Directs and oversees wellness health coaching program as well as integration with all vendors, departments, and programs at the plan, employer, physician, and medical group level. Directs the worksite wellness programs that are linked to sales and marketing. Create, edit and manage program communications both pre- and post-enrollment. Consult with broker groups on how to leverage and market value added population health, wellness and disease management programs. Direct program content displayed on the health plan portal for members and physicians. Responsible for incentive content, delivery and reporting.

• Director, Management Integration

  • Jun 2002 - Jun 2003

  Initiated program structure, built high-performance medical management team, and successfully transitioned tri-state (CT, NY, and NJ) health plan following acquisition by public health plan. Evaluated medical management staff skills and assignments. Directed program reporting, analysis, and process improvement resulting in valuse-based outcomes in utilizations, cost savings, and member satisfaction.

• Director, Case Management and Utilization Management

  • Jan 2000 - Jun 2002

  Centralized medical management processes to increase efficiency and decrease health care costs across California. Supported design and implementation of proprietary medical data management system. Oversight of statewide team of associates. Coordinated proposal responses to attract new business.

• Manager, UM, CM and Prior Authorization

  • Jan 1995 - Jan 2000

  Coordinated activities in the case management, utilization management and prior authorization areas for HMO, PPO, POS and FFS products. Provided inter-rater reliability oversight for UM, CM and prior authorization. Led clinicians in effective program and utilization management.