Education and Certifications
1980 – 1982 University of Maine Orono, Me
Associate of Science-Animal Science
1987 – 1989 Cape Cod Community College Hyannis, Ma
Associate of Science-Nursing
October 2010 American Association of Professional Coders (AAPC)
Certified Professional Coder-Payer
Professional Experience
October 2011-February 2012 San Francisco Health Plan San Francisco, Ca
Manager, Utilization Management
Responsibilities included managing the day to day operations of UM Department including medical review, prior authorization and inpatient notification processes. Responsible for a team of 10 full time staff and 3 temporary staff; the staff consisted of Nurses and administrative staff.
February 2004-September 2011 Tufts Health Plan Watertown, Ma
February 2008 – September 2011
Medical Policy Program Manager III, Commercial Products
Responsibilities included the development and administration of Medical Necessity Coverage Guidelines, oversight of development of new Medical Policy programs/processes as products and benefits change, as well as oversight management of ongoing programs/processes upgrades to InterQual® Criteria.
Yearly review of Thomson-Reuters Healthcare length of stay data files and the yearly update of this data in relation to the Tufts health Plan Timeliness of Preregistration Process.
Oversaw the annual and quarterly review of code set additions/deletions. Reviewed all work of the Program Manager II to ensure that all cross walked codes and coverage determinations were accurate prior to implementation. Oversaw the review of all Medical Provider Claims Appeal Adjustments-to determine if coding guidelines were being followed and oversaw the application of reimbursement.
Participated in audits on a regular basis with Claims Operations and Plan Benefits to ensure all coding previously implemented is reflective of the payment system.
Served as a Decision Maker and Business Consultant for all committees applying to coverage and payment decisions. Meeting participation included but was not limited to Procedural Coding Implementation Team, Commercial Data Integrity Committee, and Edit Logic Committee. It was in these committees that code specific coverage, reimbursement, and other system logic was determined. Participants of these groups would outreach to the Program Manager III of Medical Policy Coding for directions regarding coverage, coding guidelines, and concepts.
Contact for Clinical Services involving any industry wide coding changes.
Business Consultant for Internal Customers – Served as a Business Consultant for other departments concerning coding concepts and guidelines. Worked closely with Actuary, Plan Benefits, Allied Health, Pharmacy Services, Provider Reimbursement, Claims Operations, and Medical Affairs Department.
February 2004 – February 2008
Supervisor, Pre-certification
Responsible for the direct supervision of all daily Pre-certification activities performed by the Clinical, analytical and support staff within my team. Act as a clinical resource to the non-clinical staff and represents the department on interdepartmental committees requiring clinical input such as but not limited to the Clinical Coverage Committee, Risk Management, and Member Appeals Committees. Responsible for ensuring that all regulatory requirements for utilization functions are met; including retrospective audit of staff performance.
February 2001 – December 2003 Spaulding Rehabilitation Hospital Boston, Ma
Clinical Manger-Admissions
Responsible for the Responsible for management of the clinical oversight of the department.management of the clinical oversight of the department. This includes management of the Liaison Representatives and the pre-admission evaluation process. Also serves as clinical resource to departmental staff, referral sources, patients and their families.
July 2000 – February 2001 Mount Auburn Hospital Brighton, Ma
Supervisor, Case Management
Responsible for the direct management of eight case ma...
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