Project Medical

N ATHAN G. S TEPHENS, E SQ .

**** ********* ****** **** *******, PA 193**-***-*** 4718 ******@*****.***

REGULATORY ATTORNEY – HEALTHCARE LAW

I am an accomplished and strategic attorney with strengths in healthcare law and management. I have demonstrated expertise in

understanding the needs of internal and external stakeholders as part of devising legal solutions that address business needs

through assisting my current employer’s 2,400 hospital clients. I have e xpertise in Medicare laws, coverage appeals, including

hospital status, NCD and LCD appeals, and other state and federal laws within the healthcare spectrum, as well as considerable

experience dealing with commercial payers. I am well positioned to assist a health system navigate the rapidly evolving

healthcare environment; for example, the new CMS rules 1455 and 1599 that will have significant impact in the near future.

PROFESSIONAL EXPERIENCE

Executive Health Resources (EHR), Newtown Square, PA

Manager, Regulatory Attorneys (April 2013 – Present)

Train, supervise, develop and mentor a team of fifteen (15) regulatory attorneys and “dotted line” reports of over fifty

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(50) operational staff.

Responsible for directing staff to perform the many of the functions detailed below, while retaining high level duties to

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ensure the team continues to provide excellent deliverables to over 2,400 hospital clients.

Charged with developing relationships throughout the Medicare environment, including Directors at CMS, MAC and

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QIC Project Mangers, as well as the State level for Medicaid matters and major commercial payers.

Lead or participate in client calls regarding Medicare appeals, operational issues or other matters, often with hospital

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“C” level contacts.

Regulatory Attorney Supervisor (June 2012 – March 2013)

Train, supervise, develop and mentor a growing team of twelve (12) regulatory attorneys.

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Perform a wide variety of time sensitive research tasks based upon requests from senior management by providing

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accurate, practical and reliable advice on regulatory and legal matters. Draft internal and client directed

communications on new developments concerning health care reimbursement regulations and programs.

Serve as department liaison to the Compliance Department to track and report on potential HIPAA infractions.

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Proficient using Salesforce to track and maintain event specific details.

Sit on a number of internal committees to provide regulatory guidance on new corporate initiatives as well as current

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practices. Provide regulatory support and education to various internal departments outside of Retrospective Appeals,

including the Sales, Marketing, Compliance, Clinical Research, and Special Projects departments.

Regulatory Attorney (January 2010 – June 2012)

Medicare responsibilities:

• Write, edit or revise memoranda to appeal denials at the Redetermination, Reconsideration, Administrative Law Judge

and Department Appeals Board/Medicare Appeals Council levels, including extensive participation in Administrative

Law Judge hearings.

• Create and regularly update learning modules that are used company wide on Medicare topics, including: the Social

Security Act sections 1861, 1862, 1870 and 1879; the Medicare appeals process; and Medicare contractors.

• Authored white papers on various topics, including: admission orders; condition code 44; inpatient and outpatient

status, and observation services.

• Perform research on client specific questions regarding Medicare regulations, guidance and process.

• Serve as point of contact for Medicare Medical Director for questions relating to Medicare processes and regulations.

Provide guidance and expertise on issues concerning Medicare Administrative Contractors (MAC), Recovery Audit

Contractors (RAC), Zone Program Integrity Contractors (ZPIC), and Quality Improvement Organization (QIO)

appeals and regulations.

Medicaid responsibilities:

• Serve as point of contact for the Medicaid Medical Director regarding state specific issues for internal process

implementation, concurrent reviews, retrospective appeals and audits.

• Created a 50 state matrix detailing the requirements for inpatient, outpatient, observation, readmission, medical

necessity and the appeals process.

• Assist physician representatives in preparing appeal letters tailored to state specific requirements.

Managed Care Organization responsibilities:

• Serve as point of contact for the Managed Care Organization (MCO) Medical Director for questions related to ERISA,

self funded, fully insured, and managed care plans.

• Created a 50 state matrix detailing the availability and process for existing external review processes.

• Examined over 250 provider manuals to create database for medical necessity, screening criteria and internal appeals

process.

• Perform research on client specific questions regarding the availability of an external review.

MAXIMUS Federal Services, King of Prussia, PA 2008 2010

Appeals Officer

Responsible for reviewing and processing potentially adverse appeals for Medicare Beneficiaries who request

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Reconsideration of the Late Enrollment Penalty (LEP) assessed by their Part D Plan pursuant to Medicare regulations.

Made reconsideration determinations on Medicare appeals based upon the Centers for Medicare and Medicaid

Services (CMS) regulations while complying with internal procedure.

Used internet and hard copy tools to research issues using federal law, federal regulations, and relevant CMS policies

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to render accurate, timely and fair reconsideration determinations while striving for a high level of customer

satisfaction. Special duties included acting as a liaison with CMS, and assisting with project plans for potential

contracts.

Performed reconsideration reviews on an as needed basis for the Medicare Part A QIC project. Assisted in reviewing

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and drafting re opening decisions, as needed, as well as perform other duties as assigned by Process Owners, such as

reviewing the reconsideration determinations of Appeals Specialists and Appeals Officers.

EFF Consulting/GlaxoSmithKline, King of Prussia, PA 2007 2008

Consultant

Legal/Compliance Consultant for top Pharmaceutical Company on project to enhance their current procedure used to

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track, monitor and report on direct and indirect payments made to Healthcare Professionals. Direct oversight of four

(4) data entry and compliance analysts.

Led project to determine the extent of the internal and external regulations impacting direct and indirect payments to

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Healthcare Professionals in the United States and the United Kingdom. Researched, compiled and created a matrix to

illustrate the impact of state statutes, pending legislation and the codes of self regulatory bodies on current and future

business practices. Reviewed and revised internal procedure and investigator contracts to accurately monitor and

capture infractions of internal policies regarding payments to Healthcare Professionals.

Led project to determine the impact and constraints of Data Privacy regulations in the European Union in maintaining

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a database and processing personally identifiable information to track payments made to Healthcare Professionals.

Created a matrix mapping internal policies and procedures against potential risks associated with the processing of

personally identifiable information.

Acted as liaison between the Finance, Legal and Compliance departments. Facilitated and led meetings between

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department heads to present findings and acquire the approval of appropriate Vice Presidents and Compliance

Officers for new procedures.

James B. Griffin, P.C., Exton, PA 2005 2007

Attorney

Transactional, Business Law and Real Estate (70%): Represented clients in business transactions, including;

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negotiating and drafting commercial transaction documents, non disclosures, non competes, mergers, promissory

notes, purchase agreements, employment contracts, stock transfer agreements, property purchase agreements, 1031

exchange agreements and asset purchase agreements for both buyers and sellers. Assisted clients with creating

corporations, limited liability companies and partnerships. Drafted corporate documents including bylaws, operating

agreements, buy/sell agreements and Shareholder/Board of Directors minutes and resolutions.

Estate Planning (25%): Drafted wills, powers of attorney, and heath care directives. Led and assisted estate

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administration projects by probating estates, including preparing formal and informal accountings, petitions and

accompanying documents.

Other (5%): Drafted and prepared a wide array of legal documents including; pleadings, interrogatories, stipulations,

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complaints, orders, and confessions of judgment. Represented clients in Chapter 7, 11 and 13 bankruptcy proceedings.

Represented both employer and employee in federal and state level discrimination actions. Drafted management

agreements and leases for clients to satisfy PLCB requirements. Assisted clients in dealing with the statutory

requirements of various state agencies including PADEP, PHRC, PLCB and DPW. General knowledge of accounting

and forensic accounting procedures, business valuations and buy in calculations.

Pennsylvania National Guard, Plymouth Meeting, PA 2009 2010

Paralegal Specialist

• Secret Clearance

• Honorable Discharge

United States Army Reserve, Fort Indian Town Gap, PA 1998 2005

Administrative Specialist

• Honorable Discharge

E D U C AT I O N

Temple University, Juris Doctor, Philadelphia, PA

Bloomsburg University, Bachelor of Arts in History, Cum Laude, Bloomsburg, PA

A D D I T I O N A L I N F O R MAT I O N

Admittance

Admitted to practice in Pennsylvania and the U.S. District Court Eastern District of Pennsylvania

Accredited by the Department of Veterans Affairs

Community Service:

Project Salute: Providing Pro Bono legal assistance to veterans on securing federal benefits

Support Center for Child Advocates: Providing Pro Bono legal assistance to advocate for abused and neglected children in

Philadelphia, with the goal of securing a permanent, nurturing environment for every child

Contact this candidate