Nonprofit health insurance company | Leader in North Carolina in transforming the delivery of whole-person care into the public sector. Servicing the public mental health, intellectual/developmental disability, and substance abuse services for over 230,000 Medicaid-eligible citizens within a total population of 1.8 million in seven counties.
Regional Leadership Team serving over 70,000 members in Tailored Plan and up to 2 PH-medical directors and 1 administrative clinical support specialist
Implemented new Tailored Plan 7/1/24
Sr. Medical Director-Physical Health | Jun 2024 to Current
Medical Director-Physical Health | Oct 2023 to Jun 2024
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Manage internal operations, external provider relationships, and subject matter expert for consistent and accurate reviews of medical interpretation and decision of level of care and appropriateness of services
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Subject matter expert for cross collaborating and process optimization between departments
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Strategy and cross-functional teamwork – Ensure clinical integrity in content, product and strategy while working with behavioral health UM (PH & BH), CM, Appeals, Pharmacy, Vendor relations, Provider network incl. contracting, Quality, Finance/claims, and Legal teams
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Data – Translate clinical needs into product features while considering business processes in a regulatory environment to leverage value opportunities. Created UM/Medical management staffing model, and PH-MD audit tool. Pull PH data to present and discuss at UM subcommittee. Provider Lookup Tool – collaborate with IT to create an accurate automated tool.
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Physical Health UM – Created physical health medical management team and operationalized the scope of work (FER/Member Appeals/Mediation)/ Create tools (policies and procedures, workstreams, UM PH-MD and Provider Handbooks) needed to build the department, transform culture, and build external provider relationships meetings. Involved in EQRO Audit as a Lead.
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Initiatives
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Serviced-Based Review – spearheaded enterprise-wide transformational initiative that includes UM, IT, Provider Network and Claims to provide a more streamlined service, strengthen relationships, and improve quality 03/2025-Current
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PH-UM Training Curriculum – creating ground up UM onboarding and maintenance training 04-Current
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OON – analyzing organizational data to identify and recommend the right tool for OON reviews 10/2024-Current
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Committee Chair and other leadership involvement
- Medical Policy Committee Chair - lead team discussions about NCDHHS’ clinical coverage policies and creation of Alliance medical policies. Develop, implement, and interpret medical policy including medical necessity criteria | 01/2024-Current
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Utilization Management Subcommittee Chair - Facilitate and lead team discussions related to projected utilization trends, drivers, and quality based on cross functional data. Lead UM subcommittee strategy to obtain NCQA accreditation through stronger analytics that aligns with accreditation standards | 02/2024-Current
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Medical Management Subcommittee Co-chair | 07/2025-Current
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Committee member: Pharmacy and Therapeutics Subcommittee, Benefits & MedEcon Workgroup, Network Performance Committee
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Duke Margolis Institute Health Policy Alliance Representative
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Problem Solving Results
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Problem: unpaid claims, solution through technology, outcome-improved customer service and saved approx. $500,000 within 3 days
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MAR 2023 to OCT 2023
Executive Healthcare Consulting
Charlotte, NC: Remote
Executive Physician Consultant
JUN 2016 to FEB 2023
Louisville, KY: Remote
Humana Inc. is a for-profit health insurance company based in Louisville, Kentucky. In 2021, the company ranked 41 on the Fortune 500 list. It has been the third largest health insurance provider in the nation.
Lead Medical Director | Medicare Advantage | Jun 2020 to Feb 2023
Mid-Atlantic Region (Jun 2020 to Dec 2022) | Southeast Region (Dec 2022 to Feb 2023)
Regional Leadership Team serving 1 million+ members and up to 27 reviewing medical directors
Leader for key regional partners in North Carolina with 300,000+ members in 38+ facilities | Implemented NC State Group Plan
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Managed internal operations, external provider relationships, and subject matter expert for consistent and accurate reviews of medical interpretation and decision of level of care and appropriateness of services | ‘20-‘23
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Humana Excellence and Leadership (HEAL) Award Recipient: Recognizes distinct members of Humana's clinical community for their commitment to the health and well-being of the people and communities served by Humana | 2022
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Steered Mid-Atlantic Region through a consolidation of regions | 11-12/2022
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Implemented and managed UM Automated Medical Director Tool-decreased TAT of cases | 10-02/2023
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Re-engineered existing process to improve end-to-end service (UM Customer Centric Initiative) | 09/2020-02/2023
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Created and led change through a medical director pod framework with outcomes:
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Improved external hospital partner relationships and internal associate experience by leveraging corporate and regional cross-functional teams
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Restructured communication flow among 7 departments
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Reduced administrative burden by 30%
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Created 1.2M cost-savings
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Maintained quality reviews > 90%
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Maintained stable voluntary turnover rate < 9%
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Created internal provider handbook
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Designed regional dashboard to monitor market metrics | 08/2022-02/2023
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Operationalized Home Health reviews in the market | 05-10/2022
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Humana’s Physician Advisory Com. | Co-chair Growth, Development and Advancement Com. | 2021-2023
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Instituted Humana medical director workday calibration nationally | 2022
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Developed digital corporate and regional physician handbook nationally | 2020
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Humana Representative at AAFP FMX in 2020-2022
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Part of the Procurement Team for selecting Humana’s education benefit | 2021
UM Reviewing Medical Director | Jul 2016 to May 2020
Through nurse collaboration, guided colleagues through daily workflow to meet compliance and work-life balance | Improved daily processes leading to creation of regional medical director policies.
High volume reviewer (avg. 40 cases/day) of Inpt. LOC, SNF, IRF, LTACH, and Surgical Prior Authorizations, & P2Ps while practicing appropriate application of CMS NCD/LCD, MCG, and Medicare Manual Guidelines.
Clinical Experience
JUN 2002 to JUN 2016
SC/NC/Remote
Practiced in Outpatient Family Medicine, Urgent Care, Home Health and Telemedicine Settings.
Healthcare Leadership Education
2020-2023
Dallas, TX
Following my residency, I had the opportunity to practice medicine in diverse settings, including outpatient clinics, urgent care facilities, home health, and even telemedicine. Throughout these experiences, I underwent personal and professional growth. I prioritized comprehensive patient care and diligently incorporated the latest continuing medical education (CME).
Motivated by my thirst for continued knowledge, I embraced unique opportunities, such as practicing telemedicine before it gained widespread acceptance. This period allowed me to further develop my strengths and interests. I took the initiative to teach and organize the first CME-approved Telemedicine Grand Rounds, deepening my understanding of how technology-based platforms can enhance healthcare delivery. Through presentations and publications, I emerged as a leader in the field of telemedicine, leveraging my expertise to contribute to the advancement of this rapidly evolving field.
Due to my passion for continuous learning and making a greater impact within healthcare systems, I joined Humana. This opportunity enabled me to delve into various aspects of healthcare, including utilization management, compliance, population health, and value-based care. In my leadership role, I have been able to leverage my skillset in operations, utilizing data analytics to inform decision-making and fostering strong external relationships.
In order to further enhance my professional performance, I made the decision to pursue a master's degree in science at UT Dallas which I completed in May 2023. This experience not only provided me with valuable insights from industry leaders but also broadened my business perspective. I find immense excitement in pursuing my dream of improving healthcare outcomes and building meaningful relationships, and the coursework at UT Dallas has played a vital role in supporting these aspirations.
Postgraduate Training
2002-2005
Concord, NH
From 2002 to 2005, I completed my medical training at Dartmouth's Family Medicine Internship and Residency program. Throughout this period, I not only honed my clinical skills but also cultivated a compassionate bedside manner, emphasizing the importance of patient advocacy and evidence-based medicine. Additionally, I had the opportunity to participate in a medical mission to Honduras, where I provided care to patients in a resource-limited environment, broadening my perspective on healthcare. I was honored to receive the Community Oriented Primary Care Award for my dedication to serving the community, and being able to publish a medical topic under FPIN, showcasing my commitment to contributing to the field of medicine.
Medical Education
1993-2000
Dublin, Ireland
I had the privilege of attending University College Dublin to pursue my medical studies after graduating from Dominican High School in New Orleans, Louisiana. During my time there, I had the opportunity to study alongside outstanding Irish and international students, and I successfully completed all coursework, developed excellent clinical skills, and seamlessly assimilated into the cultural milieu. Furthermore, I diligently passed all the necessary exams, including the USMLEs, Clinical Skills Assessment, and English proficiency exam, resulting in the issuance of my ECFMG certificate on December 26, 2001.