Develop strategic partnerships to enhance, expand and work collaboratively with Care Coordination Services.
Ensures that the CCO network complies with multiple contracts and their individualized requirements for services.
Responsible for supervising, training and evaluating direct reports including employee performance evaluations and recommending hiring/dismissal of direct reports.
Makes recommendations for future program staffing needs.
Continual development and updating of program policies and procedures.
Engages clients in care coordination activities to promote improved utilization of health services.
Provides evidence-based health assessments and screenings.
Coordinates with supervisors and other healthcare providers, hospital discharge planners, skilled nursing facility staff, and staff at the client’s home to implement services and analyze the disposition of cases both pre and post discharge.
Coordinates and provides referrals and advocacy for clients/beneficiaries to community long-term services and supports.
Maintains all required computer and documentation related to services provided in multiple databases and conforms to monthly documentation deadlines.
Reconciles billing reports and completes multiple reports for CCO leads.
Conducts required field visits and client case reviews.
Creates and conducts presentations and training one-on-one and in groups.
Health Homes Care Coordinator
Area Agency on Aging & Disabilities of SW WA
08.2014 - 06.2022
Effectively engaged and enrolled elderly disabled and developmentally disabled clients to participate in the Care Coordination state program. All services were provided in private homes, adult family homes, nursing facilities and hospitals.
Completed 60 face-to-face visits per month with all clients along with accurate and timely case notes and follow-up.
Accurately completed and promoted Health Action Plans and assessments to improve health outcomes.
Effectively organized and delivered services within strict timeframes.
Adequately adjusted timelines and job duties as needed for program changes.
Provided six core services: Comprehensive Care Management, Transitional Care Services, Referrals to Community and Social Services, Individual and Family Support, Health Promotion and Care Coordination.
Long Term Care Case Manager
Area Agency on Aging & Disabilities of SW WA
05.2011 - 08.2014
Completed accurate and timely health assessments to establish the need for an in-home caregiver. Program ensures the elderly and disabled remain and thrive in their home environment. All services were completed during home visits.
Identified and coordinated social services and medical equipment needs.
Authorized payments and services for vendors and clients.
Proficiently worked with clients from all income classes, backgrounds, beliefs and cultures.
Infant Case Manager/Community Health Worker
Cowlitz Family Health Center
11.2006 - 05.2011
Effectively engaged and enrolled high-risk pregnant mothers and their infants into the voluntary state program, Maternity Support Services.
Completed accurate and timely assessments to identify risk and unmet needs.
Completed home visits with all clients monthly.
Created and managed a clothing and equipment bank to assist client needs. This included establishing ongoing community partnerships and soliciting donations and volunteers.
Became a Lamaze Certified Childbirth Educator and Internationally Board-Certified Lactation Consultant. Developed and taught groups and private classes.
Achieved certification as a Child Passenger Safety Technician and in turn created and managed car seat safety clinics in the community.
Americorps Volunteer Recruitment Supervisor
Cowlitz Americorps Network
09.2004 - 09.2006
Supervisor for community service projects. This included soliciting donations, establishing budgets, coordinating volunteers, giving presentations and creating successful projects to better the community.
Organized and led Americorps meetings which included public speaking, problem solving and establishing a consensus.
Elected Cowlitz Americorps Leader Corps Representative for the state and completed a two-week leadership course.
Health Homes Care Manager at Department of Children, Youth & Families, Albany CountyHealth Homes Care Manager at Department of Children, Youth & Families, Albany County
Program Manager of Health Homes Care Management at AIDS Service Center of NYC/The AllianceProgram Manager of Health Homes Care Management at AIDS Service Center of NYC/The Alliance