THERESA DUMATOL
Whittier
Summary
Dedicated and compassionate healthcare professional with 16 years of experience in case management, including 9 years as a Registered Nurse (RN) and 7 years as a Licensed Vocational Nurse (LVN). Proven track record in providing comprehensive care coordination, managing complex patient cases, and optimizing healthcare outcomes across diverse settings. Expertise in developing and implementing patient-centered care plans, conducting thorough assessments, and collaborating with multidisciplinary teams to ensure continuity of care. Skilled in patient education, advocacy, and navigating complex healthcare systems, including insurance, resource allocation, and treatment planning. Committed to delivering high-quality, cost-effective care while maintaining compliance with healthcare regulations and standards.
Overview
18
18
years of professional experience
1
1
Certification
Work History
High Intensity Case Manager – Registered Nurse
Prospect Medical Group
Orange
03.2023 - Current
- Effectively manage members on an outpatient basis to ensure care coordination needs are met
- Provide complex and chronic care needs by assessing, developing, implementing, coordinating, monitoring, and evaluating care
- Prevent re-admissions and ensure that the members' medical, environmental, and psychosocial needs are optimized over the continuum of care
- Conduct assessments to identify individual needs and a specific care management plan to address objectives and goals as identified during the assessment
- Develop Individual Care Plan (ICP) by conditions identified in health plan HRA, patient assessment, medical records authorizations/referrals, primary care physician, member, and Interdisciplinary Care Team (ICT)
- Conducts outbound calls to assigned high-risk case managed members
- Occasional, in-person visits to better facilitate members’ care
- Collaborate with member, member’s family, and physicians for seamless coordination of care and services
- Conduct in-depth root cause analyses for patients who experience readmissions to determine the underlying reasons (e.g., insufficient discharge planning, lack of follow-up care, medication nonadherence, socioeconomic barriers).
- Collaborate with healthcare teams to review clinical and operational processes that may contribute to unnecessary readmissions.
- Use data analytics tools to identify patterns and trends in readmission, working to develop and implement strategies to address system-based issues that impact care continuity.
- Create reports and presentations summarizing findings and provide actionable insights to improve care protocols and reduce readmissions.
Inpatient Case Manager – Registered Nurse
Regal Medical Group
05.2017 - Current
- Perform clinical review upon admission and daily while the patient is hospitalized based on Milliman Clinical Guidelines Criteria
- Assume an appropriate level of inpatient care
- Conduct Utilization Management duties including: assess for appropriateness, effectiveness, timing and setting of medical treatments and interventions
- Monitor inpatient stays to prevent delays in service and/or report aberrancy
- Identify and resolve barriers or potential barriers to safe transition and outpatient management
- Coordinate and assure all services for care transitions including transfer to lower levels of care, transfer to outpatient management, etc
- Educate members on post-discharge instructions, outpatient physician follow-up, appropriate use of urgent care, and appropriate use of ER services
- Coordinate care for patients in the Emergency Room or Urgent Care to avoid unnecessary acute inpatient admission
- Timely documentation based on regulatory and contractual guidelines established by Federal, State, Local, and Health plan guidelines, along with policies and procedures established by the Medical Management department
- Participate in weekend rounds with the Regional Medical Director and Hospitalists
Labor & Delivery – Registered Nurse
Whittier Hospital Medical Center
02.2017 - 11.2018
- Assesses, plans, and evaluates patient care needs including obtaining patient history and assessing for labor risk factors
- Cares for patients requiring fetal assessment/fetal monitoring
- Carries out physician orders
- Manages the patient's pain including epidural and patient controlled analgesia administration management
- Administers prescribed medications and monitors vital signs
- Assists physician during delivery, treatment, examination and surgical procedures
- Serves as the primary coordinator of all disciplines for well-coordinated patient care
- Monitors, records and patient condition as appropriate utilizing computerized documentation systems
- Instructs and educates patients and families
- Provides age and culturally-appropriate care
- Follows Standard Precautions using personal protective equipment as required
Inpatient Case Manager – Registered Nurse
Whittier Hospital Medical Center
Whittier
08.2014 - 02.2017
- Perform comprehensive assessments of patients' medical, emotional, and social needs upon admission, throughout their hospitalization, and at discharge.
- Collaborate with physicians, nurses, social workers, and other healthcare professionals to develop and implement individualized care plans for hospitalized patients.
- Lead discharge planning efforts, ensuring patients have appropriate follow-up care, resources, and education for a smooth transition from inpatient to outpatient care.
- Act as a liaison between patients, families, and healthcare providers to ensure that patients’ rights are respected and that they receive optimal care and services.
- Apply clinical knowledge and evidence-based guidelines to manage patient care and make appropriate recommendations for treatment or interventions.
- Continuously monitor patient progress, making adjustments to care plans as needed to address changes in condition, treatment response, or resource needs.
- Identify and advocate for appropriate resources (e.g., medical equipment, home health services, rehabilitation) and ensure patients receive cost-effective care.
- Facilitate communication with insurance companies to obtain prior authorizations and ensure coverage for medically necessary treatments and services.
- Maintain accurate, thorough, and timely documentation of case management activities, care plans, and patient interactions in compliance with hospital policies and regulatory standards.
- Provide education and counseling to patients and families regarding health conditions, treatment options, and self-care strategies.
- Attend rounds and participate in interdisciplinary team meetings to ensure comprehensive, holistic patient care.
- Contribute to hospital quality improvement initiatives by identifying gaps in care, recommending process improvements, and participating in performance improvement projects.
- Performs daily concurrent chart reviews utilizing approved hospital criteria
- Use of Milliman Clinical Guidelines Criteria for inpatient admissions and daily concurrent review.
ER/Pre-Access Case Manager – Licensed Vocational Nurse
Whittier Hospital Medical Center
07.2011 - 08.2014
- Screens all patients for the appropriateness of admissions, targeting specific admission criteria requirements using InterQual Screening criteria.
- Responsible for discussing the screening criteria with the ED physician and admitting physician prior to registration.
- Review all status changes (e.g., observation to admission, admission to observation, extended observation status).
- Responsible for reviewing all observation statuses in-house on a daily basis and discussing with the attending MD and nursing staff the disposition of whether to admit or extend observation status.
- Coordinate transfer of patients who are out-of-network, uninsured and patients who needs tertiary care that could not be provided by the facility to another acute care facility
- Conduct Utilization Management duties, including assessing for appropriateness, effectiveness, timing, and setting of medical treatments and interventions.
- Use of Milliman Clinical Guidelines Criteria for inpatient admissions and daily concurrent review
Inpatient Case Manager – Licensed Vocational Nurse
Valley Presbyterian Hospital
09.2010 - 07.2011
- Performs daily concurrent chart reviews utilizing approved hospital criteria
- Discusses medical necessity/medical management issues with attending/responsible physician advisors, when indicated
- Facilitates transfer of patients to other acute care facilities as required
- Performs UR criteria screens of all patients and formulates discharge plans
- Interviews patients and families to obtain relevant information and develops discharge plan with input from other members of the health care team
- Perform other related duties as assigned
- Conduct Utilization Management duties including: assess for appropriateness, effectiveness, timing and setting of medical treatments and interventions
- Use of Milliman Clinical Guidelines Criteria for inpatient admissions and daily concurrent review
Discharge Lounge - Licensed Vocational Nurse
Hollywood Presbyterian Medical Center
08.2008 - 09.2009
- Monitor discharged patients based on appropriate criteria for the Discharge Lounge
- Interview patients and family members to identify post hospital care needs and arrange transportation and pick up for their final destinations
- Coordinates patient transfers between facilities
- Demonstrates the ability to provide care in emergency situations and follows established emergency procedures and practices
Visiting Nurse – Licensed Vocational Nurse
Progressive Home Health Care
10.2007 - 05.2008
- Provides one on one care in patient’s home
- Assess/observe patient’s current condition, paying special attention to any changes; implement plan of care
- Perform wound care as needed/ordered
- Check medications, update medication profile and report any changes to the home office
Nurse Case Manager – Licensed Vocational Nurse
Mila M. Mercader & Associates (Case Management Registry)
11.2006 - 12.2007
- Maintains length of stay reports and reviews for medical floors including OB/GYN, Labor and Delivery, Pediatrics, NICU and Acute Rehab
- ER Admissions Screening
- Assesses each acute care hospital admission to determine the appropriate level of care Consults with physicians regarding patient’s plan of care
- Attend Utilization Review meetings as needed
- Conduct Utilization Management duties including: assess for appropriateness, effectiveness, timing and setting of medical treatments and interventions
Education
Bachelor of Science - Nursing
Aspen University
Denver, Colorado01.2024
Associate of Science Degree - Nursing
San Joaquin Valley College
Ontario, California04.2016
Certificate of Vocational Nursing -
American Career College
Los Angeles, California10.2006
Bachelor of Arts - Sociology
University of California
Riverside, California12.2003
Master of Science - Psychiatric Mental Health Nurse Practitioner
Norwich University
Northfield, VTSkills
- Care coordination and case management
- Patient assessment and education
- Utilization management and review
- Interdisciplinary collaboration
- Effective communication skills
- Patient advocacy and support
- Teamwork and professionalism
- Clinical documentation and problem solving
- Microsoft Office proficiency
Certification
Registered Nurse, California State Board of Nursing, 07/01/16, 06/30/24, 9509639
Former Name
THERESA TABANERA
References
References available upon request.
Timeline
High Intensity Case Manager – Registered Nurse
Prospect Medical Group
03.2023 - Current
Inpatient Case Manager – Registered Nurse
Regal Medical Group
05.2017 - Current
Labor & Delivery – Registered Nurse
Whittier Hospital Medical Center
02.2017 - 11.2018
Inpatient Case Manager – Registered Nurse
Whittier Hospital Medical Center
08.2014 - 02.2017
ER/Pre-Access Case Manager – Licensed Vocational Nurse
Whittier Hospital Medical Center
07.2011 - 08.2014
Inpatient Case Manager – Licensed Vocational Nurse
Valley Presbyterian Hospital
09.2010 - 07.2011
Discharge Lounge - Licensed Vocational Nurse
Hollywood Presbyterian Medical Center
08.2008 - 09.2009
Visiting Nurse – Licensed Vocational Nurse
Progressive Home Health Care
10.2007 - 05.2008
Nurse Case Manager – Licensed Vocational Nurse
Mila M. Mercader & Associates (Case Management Registry)
11.2006 - 12.2007
Bachelor of Science - Nursing
Aspen University
Associate of Science Degree - Nursing
San Joaquin Valley College
Certificate of Vocational Nursing -
American Career College
Bachelor of Arts - Sociology
University of California
Master of Science - Psychiatric Mental Health Nurse Practitioner
Norwich University
Similar Profiles
Mayra AriasMayra Arias
Pharmacy Referral Coordinator at Prospect Medical GroupPharmacy Referral Coordinator at Prospect Medical Group
Imelda BonaobraImelda Bonaobra
Southern California Hospital at Prospect Medical GroupSouthern California Hospital at Prospect Medical Group
Amanda HandleyAmanda Handley
Inpatient Coordinator II at Prospect Medical GroupInpatient Coordinator II at Prospect Medical Group