RUTH E. THOMAS3745 Cove Court ● Jacksonville, FL 32277

Mobile (904) 674-1117ruthiems@yahoo.com

HEALTH & BUSINESS ADMINISTRATOR “Champion Business Professional, Leader, Clinician & Health Care Professional: Focused on People,

Quality, Processes & Performance”

PROFESSIONAL SKILLSMicrosoft Office & InterQual Proficiency Management and LeadershipPresentation & Facilitation Employee Motivation to enhance productivityHealth Care Regulatory Compliance proficiency Staff & Leadership Training & Development Staff & Leadership Training & Development Critical Thinking & Decision MakingQuantitative & Qualitative Analysis Communication & InterpersonalCase Management & Utilization Review Project & Resource ManagementClaims Analysis & Appeals Strategic Planning & Cost ContainmentTalent Management Human Resource Management

EDUCATION, LICENSURE and CERTIFICATIONS Master of Business Administration, University of Phoenix, Jacksonville, FL Bachelor of Science Degree in Nursing, Wayne State University, Detroit, MI State of Florida Licensed Registered Nurse Certified Case Manager Professional Academy for Healthcare Management (PAHM) Certification ACLS and BCLS Certification

PROFESSIONAL AFFILIATIONS National Association of Women MBAs and Case Management Society of America

PROFESSIONAL EXPERIENCE

Sunshine Health/Centene Corp., Supervisor LTC Case Management 2013-2016 Blue Cross Blue Shield of Florida, Clinical Account Consultant Manager 2012-2013 Blue Cross Blue Shield of Florida, Federal Employee Case Manager 2010-2012 Blue Cross Blue Shield of Florida, Health Care Clinical Analyst 2007-2010 Blue Cross Blue Shield of Florida, Geriatric Case Manager 2000-2007 DMC Rehabilitation Institute of Michigan, Quality Improvement Specialist 1997-1999 Blue Cross Blue Shield of Michigan, Facility Analyst 1996-1997 Macomb Hospital Center, (PT) Director Critical Care 1995-1996 Detroit Medical Center Sinai-Grace Hospital, Critical Care Nurse Manager 1993-1997

PROFESSIONAL PROFILE

R. Thomas

BUSINESSBusiness Analytics & Application Collecting, validating, analyzing, manipulating, and interpreting technical information including quality issues, claims data using technical business systems to develop solutions to business problems such as need for cost containment and process improvements.

Reviewed operational procedures and methods; mapped current business processes; defined and analyzed business activities; conducted benchmarking activities to identify best practices; and recommended changes for improvement.

Analyzed joint owner and regulatory issues to identify impact on current work processes and suggested alternatives, as appropriate.

Tracked, collected, and analyzed performance information and data for reporting and planning processes. Developed an understanding of and reported on the business case behind all assignments, including the

motivating factors for all stakeholders involved.

Consulting with large account decision makers Educate on appeals and high dollar claims history Educate on case management services and other cost containment initiatives/services available Identification of intervention opportunities Recommend and coordinate alternative services

Communication Skills Public Speaking before audiences from 1 to 900 Business proposal writing of up to 5000 words Advanced Power Point presentations Technical report writing Health Analytics proficiency

Software system Proficiency:Microsoft Office products, and CERM (Care Enhance Review Manager/InterQual),AHRQ (Agency for Healthcare Research & Quality), Diamond (Claims),Siebel (authorization, claims history, etc.), CMCA (authorizations, denials), CCMS and TruCare (case management), PAIS (medical record ordering & retrieval),

MANAGED CARESupervision/Management Strong leader in Managed Care, Case Management and Acute Care settings Served on the financial nursing committee and assisted with the departmental operating budget for effective

allocation and utilization of resources Provided training on Case Management, Disease Management (CHF, MI, Diabetes, CAD, COPD, HIV,

obesity), Utilization Management (hospitalizations, oncology, hospice, skilled nursing), and Cost Containment initiatives

Instrumental in implementing a medical record paperless system 30% below the targeted budget Provided staff instruction on the Managed Care referral system, infection control and team concept nursing Reviewed nursing data, facilitated staff education on Agency for Health Care Administration and Joint

Commission preparation, documentation. Performed audits for survey readiness Conducted interviews, monitored schedules, disciplined staff and conducted performance appraisals for

reward, staff development or to identify areas of improvement Directs the preparation and monitoring of the Division’s annual budget, maintaining cost containment

initiatives and ensuring appropriate allocation of resources Attends community meetings and networking events related to Health Care Reform, Managed Care, and

services for seniors and disabled adults Provide Change Management and diversity training to staff

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Provide Performance Management, Performance Improvement Planning, and employee motivational initiatives

Establishes and communicates the mission and goals of the organization and department to enhance internal and external customer understanding

Coaches and provides direction and support to my case management team to ensure internal and external customer satisfaction

Coaching, managing, and development of high performance teams Strong fiscal management and budget experience Solid negotiating skills Case Management: Federal Employee Program and Geriatrics Coordinate discharge planning, transitional care, case management and utilization review for Federal

Employees Provide Medicare Advantage and Tricare seniors with education on health promotion and community

resources Provide education on ER readmission, diversions, referrals and facility transition for clients with complex

health care needs Serve as a liaison and network with members, providers, sales, marketing and management; resulting in a

20% increase in member enrollment in 2011 Coordinated services and benefit administration for Medicare Advantage, PPO and HMO commercial

members Worked collaboratively with case management, utilization review and discharge planning units to establish

processes to expedite transition of members to the most appropriate cost effective setting Received “Blue Treasure Chest” award and “Most Valuable Team Player” award for exemplary teamwork,

networking initiatives and cost containment saving of $5 million dollars in one year Worked closely with sales and marketing teams to promote insurance product offerings

COMPLIANCE

Leadership and Compliance Initiatives Educated and ensured AHCA compliance scores over 95th percentile for direct reports Demonstrated a strong knowledge of governing bodies (URAC and CMS) ensuring a 100% compliance rate Conducted panel clinical research for the PPO and HMO; facilitated the internal review panel and presented

cases to the Senior Medical Director Provided extensive claim review and analysis for various insurance products and recommended

administrative payment options on cases warranting payment or for claim adjudication Verified CPT and ICD-9 codes submitted on claims data, reviewed provider appeals and clinical summaries Provided pre-certifications for acute hospital admissions and physical rehabilitation and provided concurrent

review and discharge planning Facilitated staff education, preparation and documentation for the CARF accreditation and survey process Educate staff and medical providers on HEDIS and STARS measures to identify needs, gaps in services, and

to develop process improvement projects to prevent future gaps in care

QUALITY MANAGEMENTPerformance Improvement Monitored rehabilitation services and reported quality issues or any potential issues as well as providing

formal presentations on results Coordinated performance improvement initiatives to identify specific indicators, establish thresholds, increase

member enrollment and generate cost savings Utilized performance improvement tools to collect and analyze data, then used data to identify problems (root

cause), determine solutions and implement processes for improvement Reviewed benchmark reports and conducted research on evidenced based practices as it relates to more

effective delivery of nursing and rehabilitative care

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Conducted research and provided education on third party payers, regulatory compliance and informatics to staff, providers and patients

NURSINGCritical & Ambulatory Care Managed a team of 156 Critical Care Nurses in a major trauma acute care hospital Monitored pre/post op patients and critically ill patients; administered multiple medications, assessed and

documented patient progress while working closely with doctors for treatment Served as a nurse preceptor and provided education on intracranial pressure monitoring and Swan Ganz

Catheterization to monitor the hearts function and overall blood flow Provided nursing care in a multi-physician clinic to adult and pediatric patients; services included injections,

cardiac monitoring, respiratory and case management Educated staff and patients on managed care and ensured HIPAA compliance when assessing the patient,

taking medical histories, documenting progress or releasing information

TALENT MANAGEMENT

Human Resource Management Provided Talent Management/ Recruitment Services for Long Term Care Management, Case Management,

Disease Management, and medical-surgical venues Hired highly-skilled Organizational Talent Performance Management and Professional Development of Registered Nurses, Licensed Practical Nurses,

Certified Nurse Assistants, Nurse Technicians, Administrative Support, Information Technologists, and Program Coordinators

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