Carolyn Goddard
Director of Medical Policy @WellSense Health Plan
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WORK HISTORY
Director of Medical Policy @WellSense Health Plan
Charlestown, MA, US
Responsible for the oversight and management of end-to-end processes for the Medical Policy Program. Work collaboratively with the VP and Senior Medical Directors to establish and prioritize effective strategic initiatives that ensure clinically appropriate and cost-effective managed care for Medicaid, Medicare, and commercial members. Validate that medical necessity criteria are in compliance with contractual, regulatory, accreditation, and payment guidelines and are consistent with criteria used by partner clinical vendors and pharmacy services. Lead policy transformation efforts, including defining criteria for new policy development, ad hoc reviews, and retiring policies based on data-driven prioritization. Standardized the policy review and implementation process to achieve departmental goals for all lines of business in established markets; ensure that evidence-based medicine, published scientific research, and nationally recognized professional guidelines are used to develop objective, unbiased criteria; and utilize benchmarking to validate guidelines are consistent with competitors. Serve as Chairs the Medical Policy Committee and act as the primary subject matter expert for the Medical Policy Program for RFPs, state agencies, NCQA, EQRO, mental health parity NQTL, vendor implementations, product implementations, and other projects. Manage the Medical Policy team responsible for clinical reviews, market analyses, code reviews, system configuration, utilization analyses, and policy implementation. Maximize operational efficiencies and product output with ongoing intradepartmental process improvement initiatives with staff and collaboration with cross-functional teams with business leaders, subject matter experts, clinicians, consultants, and/or vendors to consistently meet project deliverable dates.
EDUCATION
University of Massachusetts Lowell
Master's degree
University of Massachusetts Lowell
Bachelor of Science - BS
ABOUT CAROLYN GODDARD
Highly motivated, knowledgeable, and effective healthcare professional with extensive managed care experience in medical policy management, operations, contract negotiations, fee schedule and reimbursement rate development, project management, data analyses, new product development and implementation, account management, coding, clinical auditing, and utilization management.
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