Claudia Wells

This position is responsible for benefit eligibility and/or recertification decisions, identification and coordination of care,providing information and offering referrals. This position interacts directly with the insured or their legal representative, providers,and health care professionals to provide accurate, timely, and responsive replies and resolution.

Clinical Services

• Gathers pertinent information for evaluation and to determine benefit eligibility or recertification
• Makes eligibility decision based on dependency information in accordance with contract provisions, department policies and procedures, and within stated metrics
• Develops plan of care based on claimant's needs
• Documents any exceptions made and approved to existing department policies and procedures
• Advises supervisor of any critical issues

Communication

• Provides explanation of insurance plan and benefits
• Assists claimant/or their legal representative to maximize the use of their insurance dollars
• Responds to telephone and witten inquiries regarding various aspects of care coordination
• Provides information and referral services as needed
• Acts as an advocate for the claimant

Clinical Risk Management

• Informs management of potential legal, fraud, or customer complaint issues
• Participates in high risk reviews, as necessary
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• Educated patients and families on medical-surgical procedures, therapeutic regimens and pain management techniques.
• Managed caseload of up to 10 patients simultaneously by providing bedside care, treatments, IV therapy and wound care.
• Started intravenous fluids, administered medications and documented patient charts by recording food and fluid output and intake.
• Managed patients' pain by implementing pharmacological and non-pharmacological pain management interventions.
• Documented patient plan of care by taking into account nursing interventions, diagnosis and expected patient outcomes.
• Managed patients recovering from medical or surgical procedures.
• Administered medications and treatment to patients and monitored responses while working with healthcare teams to adjust care plans.

• Collaborated with physicians to quickly assess patients and deliver appropriate treatment while managing rapidly changing conditions with anticoagulation medication therapy
• Educated patients, families and caregivers on diagnosis, disease process, management and lifestyle and dietary precautions
• Provided clinical monitoring for patients on anticoagulant medication therapy. Adjusted medication doses based on physician protocol
• Provided direct patient care, stabilized patients and determined next course of action regarding anticoagulation medication therapy.

• Responsible for the Telehealth department operation within the Home Health department
• In home visits to patients with vital signs outside of parameters
• Ongoing communication with patient providers to notify health concerns monitored by telehealth equipment.
• Coordinate scheduling of urgent physician appointment for patients with vital signs falling out of normal parameters.
• Coordinate scheduling of urgent physician appointment for patients with vital signs falling out of normal parameters.
• Ongoing assessments for patient appropriateness for Telehealth Program
• Responsible for ordering Telehealth equipment and communication/troubleshooting with vendor

• Determined and addressed individual home care and hospice needs by completing detailed assessments and reviewing documentation.
• Provided physical assessments, medication and chronic and acute disease management education and clinical care to home health patients.
• Provided clinical care, emotional support and education to hospice patients and families at end of life
• Responsible for 24 hour on call hospice responsibilities including 24 hour visits and death pronouncements.
• Advised and coached patients progressing from hospitals, rehab facilities and other medical organizations to at-home treatment settings.
• Documented patient vitals and conditions to communicate concerns to physicians.
• Worked with multidisciplinary team to carry out successful treatment plans for diverse acute and chronic conditions.
• Introduced changes to patient care plans based on regular evaluations and patient changes.
• Collaborated with vendors to procure medical equipment, supplies and services.
• Educated family members and caregivers on patient care instructions.
• Evaluated patient histories, complaints and current symptoms.
• Communicated with healthcare team members to plan, implement and enhance treatment strategies.
• Documented admission, Recertification, resumption of care and discharges using Medicare OASIS forms
• Prioritized diagnoses using ICD codes

• Evaluated treatment outcomes and implemented care according to care plan to patients in the short term psychiatric inpatient intensive care, secure unit.
• Collected and documented data and prioritized cases in accordance with standards, policies, procedures and guidelines.
• Administered medication and provided 1:1 therapeutic communication and assessed and documented outcomes
• Identified patient risks, gaps in care and knowledge deficits to prevent exacerbation of illness and hospital admissions