Celeste Thomas
Riverview,FL
Summary
Skilled Utilization Manager knowledgeable about monitoring metrics and maximizing team success in fast-paced acute clinical settings. Performance- and quality-driven with more than 15 years of experience. Natural leadership talent with motivational approach. Highly motivated with a desire to take on new challenges. I'm a loyal, devoted employee with customer service, multitasking and time management abilities.
Overview
33
33
years of professional experience
1
1
Certification
Work History
Utilization Management Manager
Tampa General Hospital Emergency Room
Tampa , FL
03.2018 - 05.2024
- Monitored staff performance, identified and addressed daily issues
- Maintained operational standards each day, for example monitored shift change functions
- Enforced customer service standards and resolved customer problems to uphold quality services by ensuring medical necessity met for level of care rendered
- Recruited and hired qualified candidates to fill positions
- Resolved conflicts between employees by providing guidance on company policies and procedures
- Led team meetings and one-on-one coaching sessions to continuously improve performance.
- Enhanced team member performance through use of strategic and tactical approaches, motivational coaching and training.
- Maintained up-to-date records of employee attendance, payroll information, vacation requests.
- Managed vendor relationships by negotiating contracts and ensuring timely delivery of goods and services.
- Created monthly reports for senior management summarizing operational performance metrics.
- Monitored budgets and expenditures to ensure cost-effectiveness while maintaining quality standards.
- Established processes to ensure efficient workflow throughout the organization.
Utilization Management Supervisor
Tampa General
Tampa , FL
02.2015 - 03.2018
- Performed root cause analysis on denied claims and identified areas needing additional training or process improvement.
- Reviewed denials for appropriateness according to policies, procedures, guidelines and regulations.
- Monitored performance metrics related to utilization management outcomes such as length of stay and episode duration, readmission rates.
- Collaborated with Quality Assurance team on initiatives designed to improve quality of care while reducing costs associated with healthcare delivery.
- Assisted with the development of new or revised policies, procedures, protocols, forms and reports related to utilization management services.
- Facilitated interdisciplinary meetings between Utilization Management staff and other departments as needed.
- Maintained up-to-date knowledge base regarding changes in laws and regulations impacting Utilization Management functions.
- Conducted audits of case files to ensure accuracy and completeness of documentation according to standards set forth by the organization.
- Analyzed medical records to assess whether requested services met criteria based on evidence-based guidelines.
- Provided education to staff regarding utilization management processes and best practices.
Utilization Review Team Lead
Tampa General
Tampa , FL
04.2009 - 02.2015
- Provided education to staff on utilization management principles and processes.
- Established relationships with external vendors providing utilization review services.
- Researched best practices in the field of utilization management.
- Participated in peer-to-peer discussions about complex cases requiring authorization or denial.
- Ensured compliance with regulatory requirements related to utilization review.
- Applied medical criteria and clinical judgement to researched cases to evaluate and establish determinations.
- Referred cases to secondary review for failure to meet InterQual criteria.
- Attended conferences and training sessions related to utilization review topics such as best practices or new technologies.
- Served as a resource for staff members seeking guidance on utilization review matters.
- Organized team activities to build camaraderie and foster pleasant workplace culture.
- Collaborated with management team to implement new work procedures or policies.
- Created and distributed monthly, quarterly, and annual reports to management regarding performance.
- Provided support to staff during peak periods of workloads.
- Created training materials and conducted group trainings on new processes or procedures.
Case Manager Team Lead
Tampa General
Tampa , FL
05.2005 - 04.2009
- Developed trusting relationships with social services, health care providers and governmental agencies.
- Participated in regular team meetings and in-house training sessions to boost group effectiveness.
- Adhered to ethical principles and standards to protect clients' confidential information.
- Collaborated with healthcare team to improve care quality, reduce costs and gauge patient progress.
- Collaborated with medical professionals to coordinate treatment plans for clients.
- Facilitated communication between clients, families, caregivers, social services and other agencies to ensure client needs were met.
- Consulted with staff on resolution of complex service issues.
- Provided leadership and guidance to team members, ensuring that tasks were completed on time and to a high standard.
- Promoted to leadership position in recognition of strong work ethic and provided exceptional customer service.
Case Manager
Tampa General
Tampa , FL
04.1999 - 05.2005
- Established strong work network by building professional relationships with physicians and fellow employees.
- Liaised effectively with patients, doctors and staff members, assessing medical charts and promoting high level of communication and interaction.
- Identified potential problems and patient care trends.
- Collaborated with nursing staff to advocate for individual patient needs and insurance coverage.
- Troubleshot and resolved complex customer service issues to enhance patient and family experience.
- Followed up with discharged patients after they left the facility to ensure they were receiving adequate post-care support.
- Participated in weekly case conferences with members of the healthcare team for each assigned patient.
- Conducted assessments to evaluate the physical condition of patients prior to discharge from hospital.
- Facilitated communication between patients, families, and care teams.
Registered Nurse
Tampa General
Tampa , FL
05.1991 - 04.1999
- Administered medications and treatments, monitoring patients for reactions and side effects.
- Adhered to infection control procedures to facilitate safe, clean patient environment.
- Recorded patient condition, vital signs, recovery progress and medication side effects.
- Acted as patient advocate and implemented total patient care through team nursing process.
- Provided patient and family health education focusing on self-management, prevention and wellness.
- Created, implemented and evaluated patient care plans with medical team.
- Ensured compliance with regulatory agencies such as The Joint Commission and Centers for Medicare and Medicaid Services.
- Evaluated effectiveness of interventions through ongoing assessment of patient responses.
- Achieved departmental goals and objectives by instituting new processes and standards for in-patient care.
- Performed wound care, including dressing changes and infection control measures.
- Provided compassionate emotional support to patients and families.
- Developed strong rapport with patients through active listening skills.
- Collaborated with interdisciplinary healthcare team to optimize patient outcomes.
Education
Master of Science - Organizational Leadership
Grand Canyon University
Phoenix, AZ07-2017
Bachelor of Science - Nursing Science
Western Governors University
Salt Lake City, UT07-2014
Associate of Science - Nursing
Kennesaw State University
Kennesaw, GA05-1990
Skills
- Healthcare Systems Understanding
- Medical Terminology Familiarity
- Utilization Review Expertise
- Quality Assurance Practices
- Time management mastery
- Healthcare Regulations Understanding
- Decision-making capabilities
- HIPAA compliance awareness
Accomplishments
- Met stretch goals for the last 3 years: Decreased the number of reviews required by the Utilization Management nurse by 50%, decreased the number of denials and appeals by 5% and increased the ROI by 7%
- Invest and improved documentation and level of care management: Level of care documented by 40% in EPIC UR dashboard, authorization clearly documented in EPIC reducing denials
- Reduced All Cause 30 day readmissions: UM assist in readmissions by reviewing charts for medical necessity to validate patient stay and communicate discharge requirements based on contract needs supports the team in complying with the regulatory requirements and change in financial responsibility and denial avoidance
AREAS OF PROFICIENCY:
EPIC
INTERQUAL
WORD
Certification
- UTILIZATION REVIEW Training - 2023. INTERQUAL SPECIALIST
- UTILIZATION REVIEW CERTIFICATE / UR BOOT CAMP Training - 2024
- MASTER OF NURSING License - 2017
References
References available upon request.
Timeline
Utilization Management Manager
Tampa General Hospital Emergency Room
03.2018 - 05.2024
Utilization Management Supervisor
Tampa General
02.2015 - 03.2018
Utilization Review Team Lead
Tampa General
04.2009 - 02.2015
Case Manager Team Lead
Tampa General
05.2005 - 04.2009
Case Manager
Tampa General
04.1999 - 05.2005
Registered Nurse
Tampa General
05.1991 - 04.1999
Master of Science - Organizational Leadership
Grand Canyon University
Bachelor of Science - Nursing Science
Western Governors University
Associate of Science - Nursing
Kennesaw State University
- UTILIZATION REVIEW Training - 2023. INTERQUAL SPECIALIST
- UTILIZATION REVIEW CERTIFICATE / UR BOOT CAMP Training - 2024
- MASTER OF NURSING License - 2017
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