PANKAJ GUPTA (PK), M.D., M.B.A.

** ********** **** • Edison, NJ 08820 • 860-***-**** • adgldd@r.postjobfree.com Seasoned physician executive with 20 years of managed care (payor) experience with expertise in optimizing medical management programs to positively impact health care quality, cost, and outcomes. Extensive clinical and population health management skills, Clinical Operations knowledge, expertise in strategy, change management, healthcare analytics, reporting, D-SNP and MLTC utilization, DRG up-coding, and strong collaboration skills.

Senior Medical Director November 2017- May 2020

EmblemHealth is a New York not-for-profit health insurance company with a longstanding history of caring for New Yorkers and a commitment to creating healthier futures for our members--through innovation and consumer-centric care. We manage 3.1 million lives.

• Reduced inpatient Admits/1000 from 81.1 to 70.6 A/1000 (YTD)

• Reduced # of inpatient cases with LOS (length of stay) > 15 days from 2352 (2018) to 1280 (YTD)

• Applied "Observation" for ambulatory-sensitive diagnoses

• Collaborated with the Claims Department to conduct a clinical review on high-priced claims

• Presented CMS Office of Inspector General audit findings to the Special Investigations Unit on DRG up- coding

• Implemented a transfer policy (acute inpatient to acute inpatient) consistent with the CMS Office of Inspector General audit results and concomitant CMS transfer policy

• Implemented Joint Operating Committee post payment review with hospital systems

• Re-organized Utilization Management inpatient and outpatient cases into PODS structure to facilitate communication and collaboration with hospital systems Medical Director, Emblem Health February 2017 - November 2017

• Responsible for providing clinical expertise and business direction in support of medical management programs to promote the delivery of high quality focused medical care. Chief Medical Officer, New York State Senior Whole Health November 2014 - November 2015 Senior Whole Health NY was founded in 2012. SWH NY and has offerings of MLTC (Managed Long Term Care) and FIDA (Fully Integrated Dual Advantage). The FIDA plan is for New York City members who have both Medicare and Medicaid who require long-term services and support (LTSS). SWH integrates all Medicare, Medicaid and Medicare Part D Pharmacy benefits into a cohesive, comprehensive and easy to use plan.

• Redesigned clinical staffing model to optimize productivity of field-based nurses

• Introduced technology-based enhancements to increase efficiency of care coordination

• Enhanced care management programs for “high severity” membership

• Implemented Quality Program to meet NYS MLTC Quality Incentive Bonus

• Revamped UM process in order to gain operational efficiencies and to comply with State, Federal requirements and timelines

Regional Medical Director, Mid-Atlantic Region, Humana November 2013 - November 2014

• Oversight of the Commonwealth Coordinated Care Program (Dual Eligible Demonstration) in Virginia

• Clinical liaison between payor and providers in optimizing care of members Regional Medical Director, Affordability: North East Region 2011 – 2013 Medical Director, Inpatient Care Coordination Team: Northeast 2007 - 2011 United Healthcare, Community & State

MEDICAL COST SAVINGS

Exceeded 2011 Year End HCQAI savings for the Northeast region by $87.2 M Implemented innovative utilization management processes that reduced Bed Days/1000, Admits/1000 Strategies include:

• Transitional Nurse (real-time discharge planning)

• Proactive case management

• Multi-interdisciplinary Rounds

Implemented Medicare Readmission Letter Campaign to PCP (January 20 10) and reduced readmissions by 50% REVENUE MAXIMIZATION

Implemented UM SOP’s (standard operating procedures) which propelled AmeriChoice, NY to obtain the best 2010 PQI (Prevention Quality Indicators) score out of 18 State Managed Medicaid plans: 20 out of a total 20 points. PQI’s quantify hospital admissions that most likely could have been avoided through high- quality outpatient care.

Supervision of Medicare revenue maximization activities to lift RAF scores on chronically-ill members and direct strategy planning with CAS INGENIX market research team

Provide leadership and medical expertise in the development, implementation, and medical interpretation of medical/quality/disease management policy, procedures, and guidelines CLINICAL OPERATIONS

· Appointed by Regional CMO to be “subject matter expert” for complex Medicare Cases for the Northeast region

• Oversee daily inpatient census management

• Collaborate with multidisciplinary team for member-centric management of health resources

• Interact with community network physicians and hospital leaders

• Outreach to PCP’s with high BCR

DATA ANALYSIS

• Daily review of benchmarks: Admits/1000; Bed Days/1000; Readmission rate; ALOS.

• Proficient in Milliman Care Guidelines

• Proficient in HEDIS® QARR and CMS Star Program

Medical Director, HealthCare Management, Horizon Blue Cross Blue Shield, Newark, NJ March 2006- November 2007 MEDICAL MANAGEMENT: Utilization Management

• Achieved > 98% Stability of Initial Determinations (% Total Managed Days with Unchanged Determinations following Appeals Process) for last 20 months

• Implemented JRRP (Joint Replacement Recovery Program): URAC approved Goal: reduce LOS for elective joint replacement surgery in post-acute setting

• Provide medical leadership, oversight and consultation for Quality Improvement and Utilization Management programs including development, implementation, evaluation and compliance.

• Develop, implement and interpret medical policy including medical necessity criteria, clinical practice guidelines and new technology assessments.

• Oversee utilization management of acute and post-acute services

• Voting Member

Clinical Issues Committee

Quality Case Review Committee

Pharmacy & Therapeutics Committee

• Direct the utilization review process and oversee the quality of utilization determinations CLINICAL OPERATIONS

• Ensure compliance with clinical goals through monitoring care management performance. DATA ANALYSIS

• Proficient in Milliman Care Guidelines

Associate Medical Director, Utilization Management, HealthCare Partners, IPA, July 2005- March 2006 Management Services Organization, Garden City, NY

MEDICAL MANAGEMENT: Utilization Management

• Achieved targeted Managed Medicare care utilization reduction of hospital inpatient and skilled nursing facility inpatient days (days/1000 members/year) for organization’s high-risk Managed Medicare members as a result of medical management and implementation of Priority Care Program (Chronic Care Improvement Program)

• Provide support to Case Managers by establishing on-going communication with network’s hospitalists and community physicians to discuss complex cases and management strategies

• Member

Medical Advisory Committee

Presented Guidelines for Virtual Colonoscopy, Wireless Capsule Endoscopy, Kyphoplasty Credentialing Committee

Utilization Management Committee

Quality Improvement Committee

• Developed Hospice Program

CLINICAL OPERATIONS

• Review outpatient authorization requests

• Perform chart review for appeals process

DATA ANALYSIS

• Proficient in Milliman Care Guidelines and InterQual Criteria CLINICAL EXPERIENCE

Medical Director, Genesis ElderCare- Kimberly, Windsor, CT June 2003 – June 2005 Associate Medical Director, Wethersfield Health Care Center, Wethersfield, CT Staff Geriatrician, Hartford Hospital, Hartford, CT MEDICAL MANAGEMENT: Quality Oversight & Clinical Operations

• Supervised utilization management, Public Health Code compliance, and quality improvement initiatives in 150 bed skilled nursing facility specializing in dementia care

• Collaborated with nursing leadership and pharmacy provider NeighborCare Inc. to implement first Pharmacy Review Committee

• Developed “Preferred Partnership” with Hartford Hospital to assure continuum of care of frail elderly patients from tertiary care hospital to facility’s Post Acute Unit Staff Physician, Department of Medicine, Hebrew Home & Hospital, West Hartford, CT July 2001 – October 2002 CLINICAL OPERATIONS

Medical Director, SummerWood at University Park, Hebrew Health Care, West Hartford, CT

• Managed medical clinic for new 66 - unit assisted living facility

• Implemented marketing campaign to the greater Hartford community on hospital medical services Medical Director, Outpatient Services, Hebrew Health Care, West Hartford, CT

• Medical supervision and management of organization’s multi-site adult day centers and home care communities servicing 1,200 patients

• Streamlined intake process for new patients and organize evaluation process for existing patients House Physician, Department of Medicine, Kent County Hospital, Warwick, RI July 2000 – July 2001 CLINICAL OPERATIONS

• Nighttime coverage of inpatient ICU, CCU, medical, surgical wards INVITED PRESENTATIONS

• World Health Care Congress: Medicare Congress July 2010 Innovation in Payer and Provider Collaboration

• World Health Care Congress: Chronic Care & Prevention Congress May 2010 Reducing Readmissions through CARE COORDINATION

• World Research Group: Reducing Readmissions April 2010 Who is Responsible to Care for High Risk Patients? Improving the Infrastructure for Care Coordination Between Payer, Provider, Outpatient Facility & Community

• World Health Care Congress: Medicare Congress July 2009 Partnering in Quality Care: How Physicians and Medicare Can Work Together

• World Health Care Congress: Chronic Care & Prevention Congress May 2009 Friend of Foe: Will Aligning Reimbursement Incentives Propel Success?

• Speaker, “The Fall and Rise of Aetna.” May 2005

Presentation to the University of Hartford Executive MBA Program

• Speaker, “Code Blue:: Escalating Pharmaceutical Costs Requires Strong Medicine” February 2005 Presentation to Genesis ElderCare- Pharmacy Review Committee

• Speaker, Senior Health Initiative “Building a Mental Health Collaborative Care Unit In Assisted Living Facilities (ALFs)” January 2005 Presentation to Hartford Hospital proposing a clinical program caring for Dementia in ALFs

• Speaker, Senior Health Initiative “CONNECT: Improving Transitional Care for the Elderly” September 2004 Presentation to Hartford Hospital and Genesis ElderCare

• Speaker, General Electric Long Term Care Insurance Annual Conference August 2004

“CARING: An Alzheimer’s Disease Management Program” Presentation to GE LTC Business

• 15 Letters to The Editor New York Times addressing Medicare, Health Care Reform, Elderly http://query.nytimes.com/search/sitesearch?query=pankaj+gupta+md&n=10&prev=0&frow=0&page=1 CERTIFICATION

Medical License: NY, NJ

Board Certified: Geriatric Medicine

Six Sigma: Green Belt

CLINICAL TRAINING

Fellowship in Geriatrics, Harvard Medical School – Division on Aging July 1999 – June 2000 Beth Israel Deaconess Medical Center, Boston, MA

• Presented two Geriatric Grand Rounds to the Gerontology Department, Harvard Medical School:

“High Cost of Prescription Drugs to the Elderly: Role of the Physician”

“Managed Care and the Elderly: A Complex System Managing Complex Patients” Internal Medicine Residency, Albany Medical College – Department of Medicine July 1996 – June 1999 Albany Medical Center Hospital, Albany, NY

ACADEMIC APPOINTMENT

Senior Fellow, Jefferson School of Population Health, Masters in Chronic Care, Philadelphia, PA July 2009 David B. Nash, MD MBA, Dean

Clinical Instructor, Dept of Medicine, University of Connecticut Medical School, Farmington, CT July 2001- June 2005 EDUCATION

Cornell University, Johnson School of Business, Ithaca, NY May 2004 Executive MBA, General Management

Saint George’s University School of Medicine, St. George, Grenada June 1996 Doctor of Medicine

• Chairman, Annual Grenada Health Fair

Columbia University, New York City, NY August 1992 Post-Baccalaureate, Pre-Medical Program

Colgate University, Hamilton, NY May 1988

AB, Economics

• President, Asian Society of Colgate University

• Assistant Treasurer, Student Association of Colgate University

• President’s Award for outstanding leadership and promotion of on-campus cultural awareness BUSINESS EXPERIENCE

Assistant Manager, Citibank, N.A., Consumer Services Group, NY March 1989 – September 1990

• Performed market analysis of distribution and worth of Non-Resident Indians (NRI’s) in the United States

• Increased monthly sales from $500,000 to $1.5 million of division’s offshore investment products of foreign currency certificate of deposits to NRI’s in Mid Atlantic sales territory in 18 months

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