Open to opportunities

tamara rutledge

@tamararutledge

I lead healthcare payment integrity, compliance, analytics, and carrier relationships that improve outcomes and protect revenue.

United States

Message

What I'm looking for

I'm looking to lead payment integrity, compliance, analytics, and carrier or client engagement in a regulated healthcare environment, partnering across legal, IT, network, and operations teams to improve transparency, resolve complex issues, protect revenue, and strengthen relationships.

I've led payment integrity, utilization management, compliance, and client relations at New Era Life Insurance Companies, translating CMS, NCQA, HIPAA, and state requirements into scalable products, policies, workflows, and reporting. My work reduced FWA incidents by 40% and mitigation caseloads by 85% while protecting revenue.

I bring 20+ years across regulated healthcare operations, including provider contracting, specialty pharmacy, pediatric case management, hospital compliance, and Air Force medical operations. I use Tableau, Excel, SQL, and cross-functional leadership to resolve complex escalations, strengthen carrier and provider partnerships, and turn claims and performance data into practical improvement plans.

Experience

Work history, roles, and key accomplishments

Director, Utilization Clinical Management

New Era Life Insurance Companies, PALIC

Mar 2017 - Jun 2026 (9 years 3 months)

Executive escalation point for complex issues including regulatory reviews, medical reviews, reimbursement, and negotiations. Collaborated with legal and compliance to design and launch indemnity health payment integrity insurance and Medicare PPO products, reducing FWA incidents by 40% and mitigation caseloads by 85%.

AVP, Quality, Compliance & Utilization Care

New Era Life Insurance Companies, PALIC

May 2014 - Mar 2017 (2 years 10 months)

Led and developed a 60-member provider-facing team across compliance, quality, risk, utilization review, and peer review, sustaining 96% audit results across CMS, NCQA, HIPAA, and URAC readiness. Built dashboards and analytical insights to support leadership decisions and operational oversight.

Cross Functional Improvement Plan Operational Excellence Tableau SQL Data Visualization Data Analysis CMS TDI NCQA HIPAA Policy Development Audit Response Epic PowerPoint Word SharePoint Microsoft 365 Process Automation

Senior Case Manager, Provider Contracting

New Era Life Insurance Companies, PALIC

Jan 2004 - May 2014 (10 years 4 months)

Developed compliance standards for Medicaid, ERISA, and state laws, and wrote policy definitions for indemnity health insurance and Medicare PPO products. Audited medical claims and charge reconciliations to ensure payment integrity and prevent denials.

Compliance Medicaid ERISA Policy Development Claims Auditing Charge Reconciliation Payment Integrity Reimbursement Modeling Provider Contracting Pricing Strategy Network Performance Claims Pricing Editing

Medical Operations Leader, Air Flight Tactical Unit

United States Air Force | Wilford Hall Hospital

Led aeromedical evacuation and stabilization for critically ill patients, building leadership, escalation management, and healthcare compliance discipline in high-pressure military care settings.

Aeromedical Evacuation Patient Stabilization Leadership Escalation Management Healthcare Compliance

Medical Compliance Manager

Lovelace Health System Hospital

Led compliance, quality improvement, and operational policies, conducting regulatory governance, incident oversight, and corrective action follow-through to strengthen controls and accountability.

Compliance Quality Improvement And Operational Policies Regulatory

Medical Administration & Case Management

Seattle Children's Hospital

Managed pediatric case reviews, care coordination, and discharge planning, identifying process gaps and supporting compliant clinical and operational decision-making. Led utilization review and medical necessity decisions with clinical guidelines and payer standards.

Care Coordination Discharge Planning Utilization Review Clinical Guidelines HIPAA

Account Manager, Specialty Pharmacy & Financial Appeals

Helix Pharmaceutical Group

Managed pharmacy portfolios, ensuring reimbursement, compliance, audit readiness, and problem resolution across payer, provider, and manufacturer workflows. Led reimbursement and compliance activities for biologics, IVIG, and specialty medications.

Reimbursement Compliance Audit Readiness problem resolution Biologics Special Medications Claims Resolution