Jody Nelson MD
Minnetonka,Minnesota
Summary
Passionate and detail-oriented MD, committed to delivering high quality care to health plan members, in a cost-effective manner. Experienced in performing peer reviews. Effective leader and collaborative team player . Strong skills and ability in querying, evaluating, interpreting, and utilizing data to drive process improvement, and in new programs that reduce medical costs. Known for thriving in challenging environments and for dedication to improving healthcare delivery
Overview
22
22
years of professional experience
Work History
Medical Director, SWAT Team
CVS/Aetna
11.2024 - Current
- Provide support throughout the organization as a medical director where needed.
- Focus on educating/training medical directors.
Medical Director, Duals Center of Excellence (COE)
CVS/Aetna
09.2023 - 11.2024
- Focus on Utilization Management case review – Prior Authorizations, Inpatient, post-acute, concurrent, and prior authorization reviews
- Mentored physicians and other medical staff, facilitating professional development through training programs
- Developed FastKeys automation templates for the team to promote consistency of reviews
Senior Medical Director of Utilization Management and Payment Integrity
BLUE CROSS BLUE SHIELD OF MINNESOTA
01.2022 - 01.2023
- Company Overview: Largest health plan in Minnesota serves more than 2.5 million members across all 50 states and on four continents
- Led a team of 12 direct reports including peer reviewers, medical directors, and Vendor Delegation Oversight Team responsible for overseeing contracted peer review organizations
- Evaluated and improved existing Utilization Management Physician Peer Review process with focus on decreasing existing administrative and medical expenses
- Educated physicians performing utilization management reviews to improve quality, consistency and efficiency in their process
- Supported clinical and nonclinical payment integrity teams with vendor review and consolidation
- Key accomplishments:
- Decreased physician staffing cost while maintaining hours of coverage
- Led change in vendors providing peer review services to the company - estimated to reduce cost by 30% going forward
- Developed education and resources for internal (non-vendor) physician medical directors – including developing education materials on UM best practices, designing internal web page that brought all resources together in one place for medical directors, to increase efficiency in their daily work
- Identified issues with process of physician Payment Integrity (PI) and Special Investigation Unit (SIU) reviews
- Then developed and provided training to internal (non-vendor) physician reviewers – increased number of physicians doing PI and SIU reviews from 1 to 9
Medical Director, Lead Medical Director Utilization Management (UM)
MEDICA HEALTH PLANS
01.2017 - 01.2022
- Company Overview: A health plan serving approximately 1.5 million members in commercial, individual/family, Medicaid and Medicare lines of business across twelve states
- Began as a reviewing Medical Director, gained extensive experience in all types of health plan peer reviews including; Utilization Management, Care Management, Quality of Care, SIU, concurrent, post payment and appeal/grievance reviews
- Developed extensive familiarity with health plan policies, as well as MCG, InterQual, CMS, and Minnesota Medicaid policies and guidelines
- Transitioned into the lead medical director, supervising the other 7 UM Medical Directors
- Achieved increased consistency within Medical Director reviews by establishing documentation criteria for each Medical Director review and maintaining frequent communication with Medical Directors to promote consistency in processes and policy interpretation
- Served as Chair of the Medical Technology Assessment Committee and the Medical Policy Committee
- Provided support to the Care Management team, through individual case discussions with the Care Managers, as well as Inter-Disciplinary Team (IDT) Care Management rounds
- Led multiple education opportunities for the Care Coordination team (several hundred Care Coordinators)
- Collaborated with the Quality department to streamline quality reviews and with Legal and Operations Risk Management (compliance) to assure UM process and policy were consistent with regulations
- Provided support to the legal team by testifying at multiple Minnesota Department of Human Services (DHS) hearings and advising on insurance commissioner case inquiries
- Supported the claims /coding team in frequent clarifications of claims system setup issues
- Participated in quarterly new code reviews for claims system setup, as well as review/creation of new policy code configuration
- Represented Medica, and the Minnesota Council of Health Plans at the Minnesota Department of Health (MDH) cardiovascular disease and diabetes work group, helping to create the '2030 Minnesota Cardiovascular Health and Diabetes State Plan.'
- Created an online training manual for Medical Directors
- Managed all SIU, and Payment Integrity clinical case reviews
Urgent Care Physician
PARK NICOLLET CLINIC
01.2017 - 01.2018
Clinical Associate Professor
UNIVERSITY OF SOUTH DAKOTA SCHOOL OF HEALTH SERVICES
01.2014 - 01.2017
Adjunct Assistant Professor
UNIVERSITY OF MINNESOTA DEPARTMENT OF EMERGENCY MEDICINE
01.2015 - 01.2016
Adjunct Instructor
UNIVERSITY OF MINNESOTA DEPARTMENT OF FAMILY MEDICINE AND COMMUNITY HEALTH
01.2006 - 01.2015
Emergency Department Physician
EMERGENCY PHYSICIANS PROFESSIONAL ASSOCIATION (EPPA)
01.2003 - 01.2015
- Served as the lead physician in trauma and critical care cases at Methodist Hospital
- Promoted teamwork in every patient encounter
- Trained in and utilized Kaizen/Lean process improvement
- Coordinated resident physician and student training in the emergency department from
- Expanded the program significantly from a few residents/students a year to over 50 a year
- Initiated and maintained contacts and rotations with multiple programs in Minnesota and surrounding states
- Led multiple skills fairs for the nurses and technicians, providing education on specific topics related to patient care in the emergency department
Education
RESIDENCY - Emergency Medicine
HENNEPIN COUNTY MEDICAL CENTER
Minneapolis, Minnesota01.2003
Doctor of Medicine - with honors
UNIVERSITY OF MINNESOTA SCHOOL OF MEDICINE
Minneapolis, Minnesota01.2000
Bachelor of Arts - American Indian Studies
UNIVERSITY OF MINNESOTA COLLEGE OF LIBERAL ARTS
Minneapolis, Minnesota01.1994
Skills
- Strategic planning
- Staff development
- Clinical quality improvement
- Medical education
- Utilization management
- Process improvement
- Champion of Change
- Medical Coding
Certifications
- MD
- Fellow American College of Emergency Physicians
- Certified Health Insurance Executive (AHIP)
- Certified Professional Coder
Affiliations
- American College of Emergency Physicians, 01/97, Present
- American Medical Association, 01/96, Present
Honorsandrecognition
- Preceptor Award Recipient, 2007
- Alpha Omega Alpha Medical Honor Society Member, 2000
- American Medical Women’s Association – Janet M Glasgow Memorial Achievement Citation Recipient, 2000
- Dan Gall Memorial Human Spirit Award Recipient, 1998
Timeline
Medical Director, SWAT Team
CVS/Aetna
11.2024 - Current
Medical Director, Duals Center of Excellence (COE)
CVS/Aetna
09.2023 - 11.2024
Senior Medical Director of Utilization Management and Payment Integrity
BLUE CROSS BLUE SHIELD OF MINNESOTA
01.2022 - 01.2023
Medical Director, Lead Medical Director Utilization Management (UM)
MEDICA HEALTH PLANS
01.2017 - 01.2022
Urgent Care Physician
PARK NICOLLET CLINIC
01.2017 - 01.2018
Adjunct Assistant Professor
UNIVERSITY OF MINNESOTA DEPARTMENT OF EMERGENCY MEDICINE
01.2015 - 01.2016
Clinical Associate Professor
UNIVERSITY OF SOUTH DAKOTA SCHOOL OF HEALTH SERVICES
01.2014 - 01.2017
Adjunct Instructor
UNIVERSITY OF MINNESOTA DEPARTMENT OF FAMILY MEDICINE AND COMMUNITY HEALTH
01.2006 - 01.2015
Emergency Department Physician
EMERGENCY PHYSICIANS PROFESSIONAL ASSOCIATION (EPPA)
01.2003 - 01.2015
Doctor of Medicine - with honors
UNIVERSITY OF MINNESOTA SCHOOL OF MEDICINE
Bachelor of Arts - American Indian Studies
UNIVERSITY OF MINNESOTA COLLEGE OF LIBERAL ARTS
RESIDENCY - Emergency Medicine
HENNEPIN COUNTY MEDICAL CENTER
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