Expert: Clinical record & documentation standards

Specialties & Experience of this Expert Witness

Additional Information

As a clinical and administrative physician, my career has focused on ensuring treatment decisions and actions are completely and properly documented in the medical record. It was an honor to establish our multi-state physician group governance structures (peer review, credentialing, quality assurance and utilization management committees) and the needed feedback loops. This work stands the test of time and ensures that the medical records supplied would meet quality assurance outcomes, payment standards, and medical treatment standards at the time care was rendered. Tradewinds Healthcare Consulting, LLC 2025 - present - private consulting group providing: - expert opinion through high quality research, analysis and distilled documentation where clinical outcome(s) are in question and relevant standards are at issue - provide expert insight and support in navigating the complex Medicare Advantage industry and consistent medical decision making process(es) Humana National Utilization Committee 08/2023 - 04/2024 - Led the creation of a solution to meet meet CMS 2024 benefit rule change requirements - Accountabilities immediately described below in addition to this role Humana National Director Medicare Operations 03/2022 - 04/2024 - National Outpatient, Home Health and Grievances & Appeals Authorization - Accountable for quality, documentation, medical decision-making consistency for ~40 physicians and ~8,000,000 member benefit outcomes - selected STARS Appeals performance - Collaborate on enterprise teams and task forces Humana Regional VP Mid-Atlantic State 03/2019 - 03/2022 - Oversight of market Prior Authorization and Concurrent Review Operations - Accountable for quality, documentation, medical decision-making consistency for ~ 18 physicians and ~500,000 member benefit outcomes - Collaborate on Enterprise teams and task forces Humana National reviewing medical Director 03/2018 - 03/2019 - Reviews prior, concurrent and retro authorization requests for medical necessity Humana V.P. Integrated Care and Associate CMO 01/2015 - 03/2018 - Accountable for a multi-state primary and specialty care clinical operations - Led the creation of governance structures to manage a multi-state medical practice (Quality Assurance, Credentialing, and Peer Review) - Co-Managed medical leadership for complex divestiture / merger transaction Concentra Regional Medical Director 05/2013 - 01/2015 - Managed west coast medical operations (OccMed and Urgent Care) - Accountable for clinical outcomes, utilization and documentation across all west coast facilities Concentra Area Medical Director 11/2012 - 05/2013 - Managed Southern California medical operations (OccMed and Urgent Care) - Accountable for clinical outcomes, utilization and documentation across all SoCal facilities NuMask, Inc. 2006 - - Investor / Shareholder - Invented and secured patents, FDA filings, prototyping and manufacturing contracts Kaiser Asst Chief of Service - Emergency Medicine ~07/2008 - 10/2009 - Co-Managed ED medical operations - Accountable for departmental and individual performance in meeting clinical standards, documentation requirements and outcome measures Kaiser Clinical Emergency Medicine Physician 1998 - ~2014 - Direct patient care full time and per diem U.S.C. - Assoc. Dir. for Clinical Affairs LAC+USC Medical Center 1997 - 1998 - Managed ED medical operations for Level I Trauma and Burn Center - Responsible for departmental and individual performance in meeting clinical standards, documentation requirements and outcome measures 1984 - 1990 Paramedic NYC - Jamaica and various N.Y.C. 911 receiving hospital