Rebecca Wotherspoon MD, FAAP

• Assisted with launching the Medicare Advantage (MA) in-house in 2021, training of the staff and growth from 18,000 to 33,000 with the same three medical directors.
• Improved Medicare Advantage (MA) members patient care quality with efficient and accurate reviews for prior authorizations, acute & post acute concurrent admissions, pharmaceutical requests and appeals & grievances as well as identifying quality of care issues for Blue KC members.
• Serve as subject matter expert for MA utilization team as well as medical director lead for a dedicated Post Acute team which has consistently delivered metrics for Skilled Nursing (SNF) average lengths of stay (ALOS) which were below national benchmarks.
• Recognized for having decreased acute readmission rates for members who had been in a SNF due to identifying high-risk factors and working with case managers to address those issues.
• Serve as medical director lead for the MA Case Management/Disease Management Team and work with RNs and MSWs to assists with members at high risk for readmission and/or with complex diseases.
• Serve as medical director lead for the Commercial Neonatal ICU rounds.
• Adjudicate pediatric prior authorizations, concurrent reviews and appeals & grievances.
• Perform same state license reviews for the Commercial line of business in Oklahoma.

• Supported medical management programs to promote the delivery of high quality constituent focused medical care with directed clinical and payment policies.
• Performed utilization management and clinical claims reviews.
• Applied Medicare and Aetna clinical, coding and payment polities in the Medicare Advantage and commercial lines of business in support of the clinical claim review process, precertifications. predetermination of covered benefits and appeals process,.
• Conducted Peer-to-Peer and courtesy call back reviews with providers and members.
• Acted as a liaison between providers and the Aetna Clinical Policy Group by passing on current studies and scientific literature to support requested services.
• Attended biweekly Clinical Policy Group meetings to remain current with Aetna Clinical Policy Bulletins

• Supported multi-state medical management team ensuring timely and consistent daily acute and post acute concurrent reviews.
• Conducted hospital rounds with concurrent utilization management (UM) nurses.
• Participated in post acute (Skilled Nursing Facilities, Inpatient Rehabilitation Facility and Long-Term Acute Hospital) rounds with the post acute UM nurses.
• Provided clinical expertise in support of medical management programs through participation in Quality and Disease Management team activities.
• Medical director lead for weekly Case Management/Disease Management rounds.
• Medical director lead for Neonatal /Pediatric commercial rounds.
• Reviewed precertification requests.
• Adjudicated pharmaceuticals requests.
• Conducted Peer-to-Peer reviews.
• Responsible for Appeals and Grievance reviews
• Supported Senior Medical Director (SMD) by identifying trends that provided an opportunity to interface with medical management including provider relations, sales, healthcare delivery and national accounts to improve the quality of care delivered to members and to maintain shared business relationships.
• Supported the Territory Coach during a period when our market's SMD position was open by:

- Serving as a liaison with another market's SMD to assist with coverage of their hospitals while facing medical director shortages.

- Managing MD team schedule to assure appropriate coverage was in place for facilities and our team's nurses; and

- Helping to track trends in our market pertaining to census (e.g. NICU) and MD case volumes.

• Performed daily transactional work of individual cases from concurrent reviews and prior authorization processes.
• Conducted hospital rounds with teams of UM nurses to meet strategic direction for quality and cost outcomes.
• Conducted Peer-to-Peer reviews with providers, facilities and durable medical equipment suppliers.
• Provided medical review and support for Case Management and care coordination staff to ensure optimal care for members.
• Chaired medical and pharmacologic Appeals & Grievances committee hearings.
• Participated in Quality Assurance and Improvement activities such as identifying quality of care and adverse events as well as HEDIS rate project planning.
• Medical Director lead for a national NICU corporate savings initiative project at our local level.
• Supported staff education and training via presentations,written guidelines and coaching.

• Adjudicated pediatric and adult applications for initial and continuing Supplemental Security Income (SSI) benefits by following federal guidelines with concise and persuasive write ups.
• Reviewed medical records of applicants and when needed, ordered diagnostic studies to adjudicate claims.
• Supported disability counselors and administrators in local office as well as across the state by providing medical consultations on individual claimant cases and educational seminars for topics in areas of need.

• Diagnosed and treated a variety of diseases and injuries in a general pediatric practice setting and small community hospital.
• Managed inpatient pediatric patients including newborns with a variety of medical conditions, stabilizing and arranging transport for those who required specialty or a higher level of care.
• Attended cesarean sections and other complicated deliveries with stabilization of the neonates.
• Provided consultations for medical staff in the emergency department, inpatient and outpatient settings as well as the local health department and Oklahoma Child Protective Services

SAME AS PREVIOUSLY NOTED.

• Developed pediatric department for a federally qualified health center (FQHC).
• Diagnosed and treated a variety of diseases and injuries of a high risk population of pediatric patients.
• Provided pediatric consultations to on site family practice providers and health department staff.
• Participated in an integrated physical health/dental program.
• Developed, formatted and updated pediatric well child and common pediatric illnesses electronic medical records templates with ICD and CPT codes for clinic-wide use.
• Identified opportunities to implement best practice approaches and target affected patient populations to better improve outcomes for members with various diseases.
• Organized and led a back to school health fair, picnic and carnival promoting vaccinations and health screenings for over 600 children.
• Served as a liaison between the FQHC and the area hospitals, local health department as well as community pediatricians/sub-specialists.

• Diagnosed and managed pediatric patients in a variety of settings including outpatient practice, urgent care, emergency department and inpatient while employed in academic, hospital-employed and private practices.
• Assisted in the development and implementation of a pediatric urgent care noted for its one hour "treat to street" care within a children's hospital.
• Enhanced clinic efficiency by streamlining processes such as organizing annual high volume after hours influenza shot clinics.
• Provided general medical care at a large student health clinic with a student population > 25,000.
• Attending physician for medical students and residents rotating through general pediatric wards, outpatient clinics, pediatric private practices and emergency departments.
• Served as the pediatric clerkship director for a large medical school with four campuses providing pediatric clerkships.
• Member of the Core Clerkships, Progress & Promotions and Admissions Committees at two medical schools.