Mary Kate Thomas
Hermosa Beach,CA
Summary
Expert in Healthcare Quality, Case & Utilization Management with over 35 years of progressive experience in clinical and leadership roles. Proven success in implementing and managing auditing program for large Utilization Management system and a seven bundle BPCI program, with significant impact on patient outcomes and revenue cycle. Proficient with data collection, trending, reporting metrics, and real-time response to promote quality and facilitate performance improvement. Multi-tasking leader able to create positive workplace culture and high performing teams promoting organizational efficiency.
Overview
36
36
years of professional experience
Work History
Manager of Auditing /Utilization Management Specialist
B.E. Smith For Kaiser Permanente Mid-Atlantic
05.2022 - 09.2023
- Evaluated RN Utilization Management medical necessity reviews to assure that patients medical necessity determinations were accurate.
- Performed quality improvement audits on admission and concurrent reviews for medical necessity based upon Milliman Care Guidelines (MCG).
- Identified opportunity for cost savings for prior authorized surgeries; developed and implemented surgical audits to assure appropriate setting for ambulatory vs. inpatient care. Saved over 450K within first three months.
- Interviewed and hired employees, establishing mentoring program to promote engagement and drive operational excellence.
- Supervised and maintained referral integrity for all utilization review documentation through Epic and MCG systems.
- Submitted educational case studies to RN Utilization Management team for criteria review improvement enabling RN team to better identify medical necessity via UM review tools.
Director of Case Management and Social Services
Memorial Hospital Of Gardena
07.2019 - 03.2022
- Streamlined, standardized and implemented case and utilization management processes and procedures to promote optimal patient outcomes and positively impact revenue cycle.
- Decreased LOS to 4.1 from 5.9 in first year, and denials to less than 4%.
- Successfully navigated two TJC and CMS surveys yielding no Case Management department citations.
- Developed and administered budgets, authorized expenditures and monitored financial indicators to improve profitability.
- Decreased OT use via aggressive recruitment and retention efforts by promoting shared governance and clean/safe work environment.
- Independently developed and implemented successful BPCI program focused on quality & timeliness of care and on decreasing readmission rates via community-based care coordination.
- Exceeded 20% BPCI/CMS cap consistently within first year; with net return in 2020 - 2.8 MM.
- Supported critical CM processes so that my staff could render care in safety-net hospital throughout five Covid 19 surges.
Nurse Manager
Verity Care Connect
03.2018 - 07.2019
- Supervised professional and paraprofessional nursing staff to open new Transfer Call Center for two hospitals with total bed capacity 360 beds.
- Reviewed acute medical and psychiatric cases for medical necessity prior to admission to acute facilities, including use of InterQual to determine appropriate level of care.
- Communicated with referring facilities, Attending and consulting physicians to verify details of proposed admission and planned interventions.
- Collaborated with Managed Care providers to obtain prior authorization for proposed level of care and treatment.
- Declined and re-routed admissions not meeting medical necessity and/or lacking prior authorization, resulting in less than 1% denials for all transfers.
Acute Case Manager
Protocol Agency
07.2017 - 06.2018
- Provided acute case management services for Telemetry, ICU and Oncology units as a traveling nurse for Good Samaritan Hospital, San Jose and St. John's Hospital, Santa Monica.
- Created complex care transition plans for patients with dynamic needs to promote safe discharge from hospital to community or another acute setting.
- Collaborated closely with social workers, physicians, staff nurses, rehabilitation personnel and patient/support persons to assure patient centered, multi-disciplinary approach to care coordination.
Director of Case Management & Education
Kahuku Medical Center
06.2014 - 07.2017
- Developed and implemented inpatient Case Management and Utilization Review program for Critical Access Hospital (CAH).
- Created and presented multi-disciplinary education programs derived from established best practices for clinical and ancillary service providers.
- Created, implemented and documented job specific competency assessments for all clinical staff to comply with state and federal regulations.
- Reviewed and revised clinical policies and procedures
- Prepared for initial TJC accreditation survey for CAH, gaining full accreditation.
- Evaluated and coordinated admissions from referring facilities.
Acute Case Manager
Protocol Agency
10.2012 - 06.2014
- Provided acute case and utilization management services for multiple campuses of California Pacific Medical Center, San Francisco, and for Queens Medical Center, Hawaii as a travel nurse, managing a case load of 25-30 patients daily.
- Screened patients for medical necessity in large and busy Emergency Departments, ICU and Telemetry units.
- Provided focused education and support for patient and families regarding end of life issues and goals of care.
- Collaborated with outpatient service and supply vendors to promote smooth transition from hospital to community.
- Performed post-discharge telephonic case management to optimize patient's success in transition from hospital to community and reduce readmission risk.
Manager of Utilization Management
United Healthcare
11.2009 - 09.2012
- Evaluated medical guidelines and benefit coverage to determine appropriateness of services for over 11,000 Medicaid consumers on four islands.
- Reviewed requests for service and supply authorizations; granted authorizations based on medical necessity.
- Developed and managed robust Utilization Management department to serve state-wide Medicaid population.
Director of Case Management and Behavioral Health
Castle Medical Center
09.2005 - 10.2009
- Developed and directed hospital-wide Case & Utilization Management program.
- Managed clinical and non-clinical staff of over 60 FTE's.
- Directed 17 bed, locked Behavioral Health Unit.
- Managed budgets for two departments, decreasing yearly functioning costs by filling vacant positions and decreasing overtime use.
- Decreased LOS from average of 7.9 to average of 4.4 days
- Decreased readmission rates via Transitional Case Management program for chronic disease management.
Founder & President
Ohana Health
10.2000 - 08.2005
- Developed and executed multi-disciplinary education and training programs for multiple hospitals in Tenet Health System network.
- Assisted with, and presented for multiple successful TJC surveys, resulting in full accreditation.
- Provided medical-legal services for Los Angeles U.S. Attorney's office in medical malpractice cases.
- Reviewed individual department performance and worked with leadership to improve processes, procedures and practices
Acute Case Manager
Kaiser Mental Health Center
09.1998 - 09.2000
- Provided psychiatric case management services for inpatient population and their support persons.
- Specialized in gero-psychiatric cases, creating complex care transition plans to promote successful transition to community.
Nursing Supervisor
Chestnut Hill Hospital
02.1997 - 08.1998
- Provided nursing supervision for acute care hospital, including code response, admission coordination and crisis intervention for patients/support persons.
- Assessed daily acuity house-wide and arranged for appropriate staffing/skill mix to safely address patient needs.
Health Consultant
Hawaii Medical Services Association
10.1995 - 09.1997
- Engaged members in health and wellness education and coaching for acute and chronic disease management.
- Designed individualized wellness promotion interventions for members.
Acute Case Manager & Charge Nurse BHU
Queen's Medical Center
11.1991 - 09.1995
- Provided case management for patients with extensive medical, and/or psycho-social problems.
- Provided acute psychiatric nursing care on locked, inpatient unit.
- Established comprehensive care plans to address patient's needs and promote maximum recovery post-hospital stay.
Charge Nurse
Hospital Of The University Of Pennsylvania
01.1988 - 10.1991
- Provided psychiatric nursing care for acute inpatients in a busy urban hospital.
- Participated in, and presented complex case reviews with the multi-disciplinary teams.
- Specialized in neuro-psychiatric and gero-psychiatric patient care.
Education
Bachelor of Science - Nursing
Villanova University
Villanova, PA12.1987
Skills
- Readmission reduction
- Complex care coordination
- Joint Commission standards & compliance
- Press Ganey measures
- Continuous Quality Improvement
- Utilization Management
- InterQual, MCG
- Budget Management
- Bundled Payment for Care Improvement (BPCI)
- HCHPS performance tracking & improvement
- Cerner, Epic, Paragon
- Allscripts, Navi-Health, MIDAS
Timeline
Manager of Auditing /Utilization Management Specialist
B.E. Smith For Kaiser Permanente Mid-Atlantic
05.2022 - 09.2023
Director of Case Management and Social Services
Memorial Hospital Of Gardena
07.2019 - 03.2022
Nurse Manager
Verity Care Connect
03.2018 - 07.2019
Acute Case Manager
Protocol Agency
07.2017 - 06.2018
Director of Case Management & Education
Kahuku Medical Center
06.2014 - 07.2017
Acute Case Manager
Protocol Agency
10.2012 - 06.2014
Manager of Utilization Management
United Healthcare
11.2009 - 09.2012
Director of Case Management and Behavioral Health
Castle Medical Center
09.2005 - 10.2009
Founder & President
Ohana Health
10.2000 - 08.2005
Acute Case Manager
Kaiser Mental Health Center
09.1998 - 09.2000
Nursing Supervisor
Chestnut Hill Hospital
02.1997 - 08.1998
Health Consultant
Hawaii Medical Services Association
10.1995 - 09.1997
Acute Case Manager & Charge Nurse BHU
Queen's Medical Center
11.1991 - 09.1995
Charge Nurse
Hospital Of The University Of Pennsylvania
01.1988 - 10.1991
Bachelor of Science - Nursing
Villanova University
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