Pachavit Kasemsap
Executive Medical Director @Health Care Service Corporation
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WORK HISTORY
Executive Medical Director @Health Care Service Corporation
Scope: Executive physician leader overseeing Utilization Management (UM) for Medicare Advantage, including organizational determinations and appeals across acquired MA markets; lead a distributed team of 17 medical directors (hybrid work model); ensure consistency, quality, and compliance post‑acquisition.Selected impact & prioritiesEnsured continuity of UM operations through acquisition with no disruption to service levels or compliance.Carried forward and scaled programs originated at Cigna MA:Standardized MD onboarding to unify workflows and knowledge base.Internal auditing + inter‑rater reliability (IRR) processes to improve quality and consistency of determinations.Prior auth optimization: removed 400+ low‑ROI CPT codes, sustaining ~$3.5M/year in review‑cost reductions.Consult programs (spine surgery, revascularization) contributing ~$5M/year in medical expense reduction.Collaborate with Appeals & Grievances, Legal/Compliance, Medical Policy, Pharmacy, Network, and Analytics to align UM with affordability, quality, and member experience goals.Keywords: Medicare Advantage • Utilization Management • Appeals • Medical Policy • Quality • Compliance • Value‑Based Care • Provider Enablement • Post‑merger continuity
EDUCATION
New Mexico State University
Bachelor of Science (BS), Biology/Biological Sciences
Washington University in St. Louis
Doctor of Medicine (MD), Medicine
University of Illinois Chicago
General Surgery Residency Program
Wilford Hall US Air Force Medical Center
General Surgery Internship
University of Miami
Master of Business Administration (MBA), Health Sector Management and Policy
ABOUT PACHAVIT KASEMSAP
Physician executive and USAF veteran with a track record of improving quality, affordability, and experience across Medicare Advantage and group practice settings. I blend frontline clinical credibility with enterprise leadership—translating strategy into measurable performance in population health, value‑based care, clinical operations, and medical policy.I’ve led cross‑functional teams to elevate HEDIS/Stars, strengthen risk adjustment and documentation integrity, and streamline utilization management—all while building trusted relationships with physicians and aligning incentives to outcomes. My approach is data‑driven, patient‑centered, and execution‑focused: define the target, equip providers, remove friction, and measure relentlessly.Skills- Affordability & Utilization: Reducing avoidable admissions/ED use, readmissions, and unnecessary post‑acute spend while protecting quality- Clinical Ops Leadership: Standing up scalable processes, dashboards, and governance that turn strategy into routine- Medical Management: Tightening UM cycle times and consistency; partnering with case/disease management to target impactable patients- Medical Policy & Compliance: Applying evidence and CMS/NCQA guidance to craft clear, equitable policies and coverage criteria providers trust- Provider Enablement: Building high‑trust physician partnerships, education, and feedback loops that elevate performance and engagement- Quality & Stars: Closing high‑value gaps in care, improving patient experience, and operationalizing playbooks that move measures and sustain gains- Risk & Documentation: Improving HCC accuracy, CDI workflows, and audit readiness to ensure compliant, accurate RAF.Career- US Air Force, Lt. Colonel- Private Practice, General Surgery- Physician Executive
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