Felicia Garza
Umpqua Health Alliance, LLC
Baytown,TX
1
Certification
11
years of professional experience
Strategic nurse with 10+ years of leadership experience driving Utilization Management, Appeals, Grievances, Care Management, Quality Improvement, and Regulatory Compliance across large managed care organizations. Expert in leading high-performing teams, training improvements, optimizing workflows, strengthening regulatory performance, and elevating enterprise-level outcomes. Known for decisive leadership, operational excellence, and a member-centered approach.
Work History
Director of Utilization Management, G&A
2 Years 7 Months- Lead enterprise-wide Inpatient & Outpatient UM operations, overseeing 40+ licensed and non-licensed professionals.
- Direct strategic planning, training program, productivity management, and operational performance across all UM functions.
- Develop, refine, and implement UM workflows, policies, and procedures aligned with state contract requirements.
- Serve as primary liaison with state partners for UM deliverables, compliance, audits, and regulatory reporting.
- Provide executive oversight of appeals and grievances, including trend analysis, regulatory adherence, and collaboration with the Medical Director.
- Facilitate Utilization Management Committee, Medical Management Committee, and Benefits Alignment Committee.
- Partner with cross-functional departments to streamline workflows and enhance organizational efficiency.
- Monitor departmental quality metrics, audit outcomes, and performance indicators to ensure operational excellence.
Owner/CEO - CPR Instructor/Trainer
4 Years- Teach and certify students in CPR through AHA and Red Cross.
- Provide comprehensive education on emergency response and life-saving measures.
- Deliver high-quality instruction aligned with curriculum, policies, and procedures.
Manager I - Utilization Management / Nurse Medical Management II
2 Years- Conducted precertification, continued stay reviews, discharge planning, and care coordination. Served as the lead trainer for new hires.
- Ensured compliance with medical policy, clinical criteria, benefits, and regulatory standards.
- Collaborated with clinical reviewers and medical directors to ensure medically appropriate, cost-effective care.
- Facilitated member transitions across the continuum of care and supported accreditation readiness.
- Trained, mentored, and audited new hires; served as a resource for lower-level nurses.
- Managed daily production, resource utilization, and team performance.
- Handled member complaints, escalations, and rapid-turnaround issues.
- Completed monthly, quarterly, and annual reporting for direct reports.
- Oversaw state quality reporting and departmental performance tracking.
RN Case Manager - Hospice & Home Health
2 Years- Managed caseload of 50+ patients; supervised LVNs and CNAs, trained all new hiring included nurses and CNA’s and Medical Assistants.
- Conducted QA and OASIS audits.
- Delivered individualized case management and coordinated multidisciplinary care.
Star+Plus Manager - Service Coordination RN
1 Year- Supported implementation of D-SNP program and developed HRA and care plan tools.
- Delivered new hire and ongoing training.
- Assisted with policy and procedure development for Star+Plus and LTSS.
Manager I - GBD Special Programs (LTSS, Star Kids)
3 Years- Managed 20 direct reports and 50+ indirect reports.
- Developed quality policies, workflows, and performance tools for state reporting.
- Led training, education, and performance evaluation for all associates.
- Managed complaints, appeals, fair hearings, and quality improvement initiatives.
- Completed monthly, quarterly, and annual reporting.
- Conducted data collection and monitored key performance metrics.
Education
MSN - Leadership & Healthcare Management
GPA: 4.0 GPA
BSN
GPA: 4.0 GPA
ADN
GPA: Dean’s List
LVN
Skills
MCG
InterQual
Microsoft Office Suite
EMR Systems
Quality & Compliance Platforms
Certification
- CPR Instructor - AHA & Red Cross
- Registered Nurse (RN), Texas
CORE COMPETENCIES
- Utilization Management Leadership
- Appeals & Grievances Oversight
- Regulatory Compliance & State Reporting
- Care Management Strategy
- Quality Improvement & Accreditation
- Cross-Functional Collaboration
- Policy & Procedure Development
- Workforce Optimization & Productivity Management
- Training, Coaching & Talent Development
- MCG & InterQual Expertise
TRAINING & DEVELOPMENT QUALITIES
- Proven ability to design and deliver impactful training programs that enhance team performance and compliance.
- Skilled in coaching and mentoring diverse healthcare professionals to foster continuous learning and professional growth.
- Expertise in developing competency-based training materials tailored to organizational needs and regulatory standards.
- Strong communication and presentation skills to engage and motivate learners at all levels.
- Adept at evaluating training effectiveness and implementing improvements to maximize learning outcomes.
- Committed to fostering a culture of accountability, collaboration, and excellence through targeted talent development initiatives.
Timeline
Director of Utilization Management, G&A
Umpqua Health Alliance, LLC
01.2024 - CurrentRead More
Manager I - Utilization Management / Nurse Medical Management II
Elevance Health / Anthem BCBS / Healthy Blue MO
01.2022 - 01.2024Read More
Owner/CEO - CPR Instructor/Trainer
CPR Master Life Saver
01.2021 - 01.2025Read More
RN Case Manager - Hospice & Home Health
Signature Health Services / Ascend Hospice
01.2020 - 01.2022Read More
Star+Plus Manager - Service Coordination RN
Community Health Choice
01.2019 - 01.2020Read More
Manager I - GBD Special Programs (LTSS, Star Kids)
Amerigroup
01.2016 - 01.2019Read More
San Jacinto College
LVN
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Lee College
ADN
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Grand Canyon University
BSN
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Grand Canyon University
MSN from Leadership & Healthcare Management
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