Loretta Smith
La Vernia,TX
Summary
Strategic and forward-thinking healthcare operations leader with 7+ years of progressive experience directing Utilization Management programs across complex, highly regulated environments. Expert in CMS, NCQA, and state regulatory requirements with a proven record of elevating clinical review performance, strengthening compliance, and driving enterprise-wide process improvements. Adept at leading large interdisciplinary teams, partnering with Medical Directors, and leveraging data-driven insights to optimize workflows, improve member outcomes, and enhance provider relationships. Recognized for building high-performing teams, navigating audits with excellence, and delivering operational results that align with organizational goals.
Overview
11
11
years of professional experience
1
1
Certification
Work History
Registered Nurse, Director Healthcare Services
Molina Healthcare, Inc.
San Antonio
03.2021 - 05.2025
- Led Utilization Management and Care Review operations in alignment with CMS, NCQA, and state regulatory requirements, ensuring compliant and efficient clinical review processes.
- Provided clinical leadership to nursing and interdisciplinary teams, including coaching, performance management, and professional development.
- Partnered with Medical Directors on clinical decision-making, policy interpretation, and medical necessity determinations.
- Directed end-to-end authorization processes, claims reconciliation, and provider case resolution to improve accuracy and turnaround times.
- Drove quality improvement initiatives focused on clinical accuracy, member outcomes, audit readiness, and operational efficiency.
- Analyzed operational and clinical performance metrics to identify trends, gaps, and improvement opportunities.
- Supported the development and optimization of UM policies, procedures, and workflows.
- Collaborated cross-functionally with Quality, Compliance, Provider Relations, and Enterprise Operations to align strategies and resolve escalations.
- Led a team of 5 leaders, 39 clinical, and 17 non-clinical staff; responsible for hiring, mentoring, and professional development.
- Implemented new state authorization processes and medical record review platforms, improving compliance and efficiency.
- Built EMR partnerships with four hospital systems and launched clinical rounds to enhance care coordination.
- Managed utilization trends to address overutilization and underutilization across therapy, DME, readmissions, and short stays.
- Represented UM at quarterly health system meetings, strengthening provider relationships.
- Presented at NCQA Biennial/Triennial and state audits, consistently achieving successful outcomes.
- Led acquisition transitions (e.g., Cigna UM), ensuring seamless integration of staff and processes.
- Standardized protocols across departments and led enterprise wide committees and task forces.
- Oversaw compliance tracking, licensure, and training for all team members.
- Fostered a culture of mentorship, accountability, and continuous improvement.
Registered Nurse, Manager Healthcare Services
Molina Healthcare, Inc.
04.2019 - 03.2021
- Managed Prior Authorization Utilization Management, reporting, and compliance.
- Mentored and developed managers and supervisors, strengthening leadership capability and operational performance.
Registered Nurse, Supervisor Healthcare Services
Molina Healthcare, Inc.
06.2018 - 04.2019
- Supervised Prior Authorization Utilization Management, reporting, and compliance.
- Mentored and developed clinical and non-clinical staff, building an efficient and compliant team.
Registered Nurse, Supervisor Concurrent Review Nurse
Maryland Physicians Care (Centene)
Linthicum Heights
01.2018 - 06.2018
Registered Nurse, Concurrent Review Nurse / Prior Authorization Nurse
Judge Group (Maryland Physicians Care)
Linthicum Heights
06.2017 - 01.2018
Registered Nurse, Operating Room
University of Maryland Baltimore Washington Medical Center
Glen Burnie
01.2017 - 06.2017
Registered Nurse, Staff Nurse I, Operating Room
University Hospital
San Antonio
08.2014 - 12.2016
Education
Master of Business Administration - Health Care Management
Columbia Southern University
07.2019
Bachelor of Science - Nursing
Wayland Baptist University
02.2014
Bachelor of Science - Biology
University of Arkansas Little Rock
01.1998
Skills
- Utilization Management Leadership
- CMS
- NCQA
- State Regulatory Compliance
- Medical Necessity Determinations
- Claims
- Authorization Resolution
- Strategic Planning
- Budget Oversight
- Process Improvement
- Operational Efficiency
- Provider Relations
- Dispute Management
- Clinical Team Development
- Change Leadership
- Cross-Functional Collaboration
- Performance Metrics
- Data Analysis
- EPIC
- Sunrise
- PICIS
- QNXT
- UMK2
- TruCare
- MCG
- InterQual
- Pega
- Microsoft Office Suite
- JIRA
- SharePoint
Certification
Texas Multi-State Compact RN License, Texas Board of Nursing, 2027-03-01
Activities
- Nurse Residency Program, University Hospital, 2016-02-01
- Perioperative Fellowship Program, University Hospital, 2015-05-01
Timeline
Registered Nurse, Director Healthcare Services
Molina Healthcare, Inc.
03.2021 - 05.2025
Registered Nurse, Manager Healthcare Services
Molina Healthcare, Inc.
04.2019 - 03.2021
Registered Nurse, Supervisor Healthcare Services
Molina Healthcare, Inc.
06.2018 - 04.2019
Registered Nurse, Supervisor Concurrent Review Nurse
Maryland Physicians Care (Centene)
01.2018 - 06.2018
Registered Nurse, Concurrent Review Nurse / Prior Authorization Nurse
Judge Group (Maryland Physicians Care)
06.2017 - 01.2018
Registered Nurse, Operating Room
University of Maryland Baltimore Washington Medical Center
01.2017 - 06.2017
Registered Nurse, Staff Nurse I, Operating Room
University Hospital
08.2014 - 12.2016
Master of Business Administration - Health Care Management
Columbia Southern University
Bachelor of Science - Nursing
Wayland Baptist University
Bachelor of Science - Biology
University of Arkansas Little Rock