James (Jim) Berger, MD, JD, CHC

Experience

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  Sharp Rees Stealy Medical Group, Inc

  Jan 1988 - Jan 1995

  Internal Medicine Physician

  Employed in General Internal Medicine, 1988-1995Chief, Division of General Internal Medicine, 1992-1994Assistant Chairman, Utilization Review Committee, 1990-1992

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  HIP Health Plan of NJ

  Jan 1996 - Jan 1997

  Physician/Utilization Review

  Practiced Internal Medicine in a clinic setting and served as a Physician Advisor working closely with nurse reviewers in Utilization Management (concurrent review, pre-certification, denials)Employed in General Internal Medicine, 1996-1997Physician Advisor, Utilization Management, 1996-1997

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  Dechert LLP

  Jan 2001 - Jan 2009

  Senior Associate

  Served as an associate lawyer in a global specialist law firm within the Mass Tort & Product Liability and Healthcare practice groups.• Focused on health care, toxic tort, and pharmaceutical product liability matters and on health care regulatory matters, including HIPAA-related and hospital credentialing issues. • Worked on teams serving as national counsel in a variety of mass tort litigations, involving a cholesterol-lowering medication, nutraceutical, diet drug, anti-psychotic, and a COX-2 inhibitor and teams serving as national counsel in toxic tort cases, including exposure to radiation and flavoring vapors. Show less

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  Executive Health Resources, an Optum Company

  Jan 2009 - Jan 2017

  Vice President, Regulatory Services

  2015-2017Reported to Vice President, Regulatory Affairs, analyzed complex regulatory and medical necessity issues.• Advised clients regarding complex regulatory payer issues in the setting of dynamic healthcare laws and regulations.• Developed arguments to support medical necessity decision-making in response to denials of Medicare, Medicaid, and commercial claims. Vice President, Advisory Services2014-2015Oversaw a team conducting medical necessity internal audits for client hospitals.• Supervised audits and analyses of medical record documentation to identify both areas of strength and potential noncompliance.• Led strategic consultations with client hospitals to identify potential regulatory issues and to assess need for internal audits and further investigations to prevent improper billing.Executive Medical Director, Strategic & Tactical Advocacy Team2011-2014Served on a team which reported to Chief Clinical Officer and was tasked with responding to urgent requests resulting from high-risk audits and investigations. • Supported clients during high-risk interactions with government agencies and payers• Conducted Medicare and Medicaid compliance education for client hospitalsSenior Medical Director, Government Appeals & Regulatory Affairs,2009-2011Worked with a team establishing department handling governmental denials.• Oversaw all aspects of Medicaid fee-for-service denial appeals• Represented clients at audits by Medicare and Medicaid contractors• Prepared and presented Medicare and Medicaid Appeals on behalf of provider healthcare institutions. Show less

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  Safeguard Services LLC

  Nov 2017 - now

  Medical Director

  Report to Northeastern Uniform Program Integrity Contractor (NE UPIC) Program Director, oversee the medical review of claims for fraud, waste, and abuse.• Oversee clinical input and medical research required for investigations and audits of providers suspected of fraud, waste, and abuse.• Collaborate with state Medicaid agencies, CMS, data analysts, and investigators to formulate audits and investigations of suspected fraud, waste, and abuse within the Medicare and northeastern Medicaid programs. Show less