Senior Medical Director
CommunityCare, Tulsa, OK (Fully Remote) (2018 to present)
Communitycare is a 115,000 member provider-owned regional health plan covering Commercial, Marketplace, and Managed Medicare business in the state of Oklahoma. The company was formed in 1993 by Saint Francis Hospital and St. John Medical Center.
Oversees Medical Management with emphasis on quality and member safety.
Seniormost clinical authority since 2024.
Provides expert leadership to a large team of nurses & other personnel.
Determines coverage of prior authorizations, concurrent inpatient review, post-claims reviews, appeals & grievances.
Develop evidence-based clinical policy.
Super peer-to-peer skills.
Key Responsibilities
Proven medical leadership experience within a managed care environment with 115,000 members
Expert in utilization management, disease and quality management, appeals & grievances
Develop, deploy, and maintain clinical policy based on best-evidence and consensus treatment guidelines
Strong understanding of evidence-based medicine, clinical guidelines, and healthcare quality improvement.
Expertise in clinical analytics. Data-driven problem solver.
Strategic thinker with excellent communication, collaboration, and interpersonal skills. Adept at presenting complex information to both technical and non-technical audiences
Subject matter expert in genetic testing, Interqual, clinical analytics
Proficient software coder, developing ad-hoc utilities for clinical analytics, workflow optimization, and improved compliance.
Key Achievements
Improved U.M. consistency and compliance by leading adoption and implementation of Interqual guidelines in 2020
Developed robust software tool to streamline Medical Director documentation and ensure consistent and compliant documentation of adverse determinations
Built, managed, analyzed, and presented a longitudinal study to mitigate network leakage.
Assumed clinical responsibilities after C.M.O. vacancies (2019-2020 and 2024-present)