Medicare Advantage Prior Auth Physician Expert

Specialties & Experience of this Expert Witness

Additional Information

As a physician leader, I have designed and implemented systems to ensure medical recordkeeping meet legal, reimbursement, and quality benchmarks. I spearheaded the development of a multi-state governance framework for both primary and specialty care groups, ensuring peer review, credentialing, quality assurance, and utilization management processes are rigorously structured and defensible. I also led the creation of an enterprise-wide Utilization Management Committee to meet CMS mandates. The committee is empowered to critically evaluate national clinical policies before adoption—aligning frontline utilization decisions with evidence-based standards. With decades of expanding leadership across diverse healthcare sectors, I bring a fair, balanced, and meticulously documented expert perspective to every case I consider. Tradewinds Healthcare Consulting, LLC 04/2025 - Present - Consulting Expert - Testifying Expert - Clinical case review Humana, Inc. 08/2023 - 04/2024 - Co-Chair Humana Utilization Management Committee - Continued in National Director role below and added these responsibilities - Lead, Launch and manage the above committee to meet CMMS mandates - Collaborate on complex workflows, governance and communication cascades - Collaborate in the creation, review and approval of all clinical coverage policies Humana, Inc. 03/2022 - 04/2024 National Director Medicare Advantage Accountable for physician UM services managing benefits for ~8,000,000 members - Collaborate with regional markets to improve clinical, quality and financial performance for both internal and external customers - Worked closely with Legal, Risk, Regulatory Compliance, corporate communications, and related enterprise stakeholders National Director - Outpatient Services - Managed physician team covering outpatient prior auth requests National Director - Grievances and Appeals - Grew team to 16 physicians with two lead physicians and managed Stars measures for Timeliness and Fairness National Director - Home Health - Managed physician team covering home health prior auth requests Humana, Inc. 03/2019 - 03/2022 Regional Vice President - Mid-Atlantic States (NC, VA, MD, DE) - Accountable for acute and post-acute inpatient physician and nursing UM services - Accountable for acute and post-acute inpatient nursing case management - Accountable for physician and nurse management of benefits for ~500,000 members - Grew team from 3 to 15 physicians with two lead physicians - Managed provider relationships, performance, and outcomes during COVID 19 - Developed COVID risk stratification tool for providers during pandemic - Responsible for integrating enterprise population health strategies in the market Humana, Inc. 03/2018 - 03/2019 National Reviewing Medical Director - Case reviews for acute inpatient and post-acute authorizations Humana, Inc. 01/2015 - 03/2018 Associate Chief Medical Officer - Vice President Integrated Care Clinical leadership for primary and specialty care physician group with ~200+ physicians and mid-level providers across ~60 centers in 5 states - Led the multidisciplinary team to create and develop internal governance committees - Licensing and Credentialing - Quality and Patient Safety - Peer Review - Clinical Policy and Physician Education/Development - Worked with Lead Pharmacists to implement and manage formulary strategies across the practice - Provided clinical leadership during a merger - spin out transaction for multiple brands - Provided direct patient care - Population Health programs - Launched cardiology and cardiac imaging practice - Peripheral arterial disease detection and prevention program - Developed COPD triage symptom tracker and self management program - Collaborator with practices to reduce ED visits and acute admission rates Additional available in my curriculum vitae in the profile attachment.