VALLEÉ ADAMS-ROLLÉ, M.D.
Harrisburg,PA
Summary
Dynamic, results-oriented Medical Director with 12+ years clinical experience involving complex patients in all areas of medicine. Proven expertise in utilization management, including case review, appeals, and denials. Provide clinical and operational leadership while maintaining compliance and regulatory requirements. Experience training and educating other physicians individually and in larger settings. Organized and dependable at managing multiple priorities with a positive attitude. Willingness to take on added responsibilities to meet team goals.
Overview
14
14
years of professional experience
1
1
Certification
Work History
Managing Medical Director
CAPITAL BLUE CROSS
01.2016 - 07.2023
- Directed and managed medical necessity decisions made by physician review team ensuring maintenance of compliance and regulatory requirements
- Confirm completion of UM case reviews
- Manage departmental budget
- Participate in Medical Policy Process, reviewed medical policies and supporting documentation ensuring reviewed cases meet criteria
- Liaised between utilization management team and appeals department decreasing unnecessary clinical appeals
- Participated in implementation of new Medical Management System, leading to decrease in administrative costs and improvement in efficiency of physician case reviews
- Reduced number of unnecessary clinical appeals, meeting with vendors monthly to review case decisions and identify and address key issues and concerns
- Conducted weekly audits of case reviews and biannual inter-rater reliability process, and provided education to staff falling below standard meeting targeted goal of greater than 90%.
- Maintained compliance with local, national and federal requirements which led to successful CMS and NCQA accreditation.
- Supervised clinical staff, providing continuous professional development opportunities and training to maintain and strengthen competencies.
- Developed quarterly and yearly objectives, goals and budgets in addition to devising suggestions to decrease spending.
Associate Medical Director
CAPITAL BLUE CROSS
01.2014 - 01.2016
- Completed daily utilization management reviews, preauthorization, claims, and denials
- Reviewed medical necessity policies and recommended coverage status on evidence-based literature
- Conducted preauthorization, concurrent review, and retrospective appeals of peer-to-peer reviews
- Participated in weekly concurrent review rounds
- Key Contributions: As Medical Director Liaison on provider appeal and grievance committee, reviewed and verified that appropriate and correct coding was applied consistently to all cases, and ensured cases were reviewed in required timeframe
- Decreased quantity of out-of-network requests from vendors by developing relationships with their key members and educating them on outreach process.
Physician Advisor
EXECUTIVE HEALTH RESOURCES
01.2010 - 01.2014
- Advised and educated advising physicians and hospital case managers in delivery of timely and cost-effective care
- Promoted efficient clinical care of hospitalized patients via telephonic communication and interactions with hospital clients
- Facilitated communication between managed care/commercial payors and providers regarding benefit coverage issues, utilization review, and quality assurance processes.
Skills
- Utilization Management Reviews
- Appeals and Grievances Reviews
- Regulatory Guidelines Compliance
- Train Employees
- Medicare Compliance
- Clinical Staff Management
- Medical Director Oversight
- Budget Management
Certification
SPECIALTY BOARD STATUS
Diplomate, American Board of Internal Medicine
STATE OF PENNSYLVANIA MEDICAL LICENSE
PROFESSIONAL AFFILIATIONS
American College of Physicians
Pennsylvania Medical Society
Timeline
Managing Medical Director
CAPITAL BLUE CROSS
01.2016 - 07.2023
Associate Medical Director
CAPITAL BLUE CROSS
01.2014 - 01.2016
Physician Advisor
EXECUTIVE HEALTH RESOURCES
01.2010 - 01.2014
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