Experienced RN Case Manager at Emory University Hospital Midtown with a strong focus on clinical assessment and interdisciplinary care coordination. Achieved a significant reduction in unnecessary length of stay through the development and execution of effective discharge plans. Proficient in problem-solving and interpersonal communication, leading to enhanced patient outcomes and overall satisfaction. Committed to fostering collaborative healthcare environments that prioritize patient needs.
Overview
28
28
years of professional experience
1
1
Certification
Work History
RN Case Manager (CM)
EMORY UNIVERSITY HOSPITAL MIDTOWN
Atlanta, GA
01.2021 - Current
Responsible for patient care coordination from admission to discharge by ensuring and facilitating high-quality clinical and cost outcomes
Procuring and securing post-acute services, coordinating and advocating for patients and families with both internal and external stakeholders, identifying and addressing potential barriers to care coordination, and complex discharge planning to foster efficient care delivery and maximize reimbursement
The RN Case Manager is primarily responsible for ensuring that the discharge plan aligns with the medical plan once the patient is cleared for discharge
They serve as a resource for physicians, the interdisciplinary care team, and the patient by interpreting external regulations and organizational policies and procedures related to discharge planning and care coordination
Completing a thorough assessment and/or psychosocial assessment to allow for timely and accurate capture of information to foster the ability to work towards a safe discharge plan
Attend interdisciplinary rounds with the care team, care conferences, and/or care team meetings
Act as a representative of both the hospital care team and the patient/family to balance patient/family choice and projected care coordination needs with the ability to execute such services
Plan and implement the best possible choice for the patient while considering various factors, limitations, and patient/family preference
Identify and recommend post-acute services and complete referrals to appropriate post-acute care providers in a timely manner
Through continuous assessment and chart review, apply critical thinking to ensure alignment and appropriateness of services as the patient clinically progresses throughout their stay
Identifies and participates in the development of strategies to reduce unnecessary length of stay (LOS) and/or resource consumption
Escalates complex cases to management and the Complex Care team, Physician advisor, and/or Ethics committee
Provide supportive and therapeutic communication to patients and families who are experiencing anxiety or stress due to illness, injury, physical limitations, and/or death
Communicate confidently, effectively, and therapeutically while being assertive and conveying an impression that favorably reflects the organization
RN Care Transitions Coordinator (CTC)
EMORY UNIVERSITY HOSPITAL MIDTOWN
Atlanta, GA
01.2013 - 01.2021
Served as a patient advocate by utilizing the essential activities of care and case management: assessment, planning, implementation, coordination, monitoring, and evaluation from admission to post-discharge
Completed risk assessment tool and identified patients that were at high risk for readmission
Identified and mitigated barriers to readmission; guided the interdisciplinary team on strategies to expedite safe discharge and to the most appropriate and least restrictive level of care
Worked closely with all Providers and the interdisciplinary team to ensure optimum continuum of care received
Provided discharge teaching and disease education to patients and families alike in a manner that patients can understand by utilizing teach-back as the basis for evaluating patient understanding
Followed up with patients post-discharge, with weekly calls for thirty days to assess the transition, confirm understanding of the discharge plan of care, address any questions, comments, or concerns
Ensured patients could afford and access medications and transportation to and from appointments; collaborated with social services when additional support was needed; assisted patients with identifying low-cost or free medication by utilizing community resources, ex, Good Rx
Lily DM program; ensured procurement of medications, supplies, equipment, etc.; assisted with preauthorization of medication with insurance companies
Scheduled post-discharge appointments with PCP and other specialties, ensured patients had access to transportation for a first follow-up appointment
Provided direct patient care to cancer patients pre and post-chemotherapy and/or radiation, monitored and treated therapy complications, including pain management, infection, nausea/vomiting, and emotional need
Post-surgical care of breast and prostate cancer patients, urology, renal, and general medical patients
Skilled nursing care to various medical patients and the ability to multitask
Served as a charge nurse on the evening shift by assigning beds, addressing patient/family/staff concerns and issues, shift assignments, assigning and delegating staff, communicating with shift administration/director, and fostering the provision of superior patient care
Carefully administer and document patient medication/dosage and interpret physician orders
Communicate directly with physicians and other integral patient-care team members
Documented patient history, assessment, allergies, and medication review accurately
Assessing and evaluating early signs of distressed patients and utilizing hospital emergent protocol to keep patients safe
Promote health and well-being by providing education to renal patients
Integral Interdisciplinary Plan of Care member by providing in-services to staff members regarding individualized patient care plans, patient/family daily goals, and discharge goals
Integral member of Peritoneal Dialysis Super Trainer Class
Excellent patient care liaison
Assisted Unit Manager in unit-based projects by collecting and reporting data
Key unit member by providing patients with a high standard and quality of care
Primary preceptor on the day shift for new staff RNs
Staff Nurse
QUEENS OF PEACE
Queens Village, NY
01.2000 - 01.2001
Direct care to residents in a long-term facility with various medical needs
Compassionate end-of-life care
Routine administration of medications
Identifying and initiating appropriate referrals for patients/families with physical and emotional needs
School Nurse
DEPARTMENT OF HEALTH
New York, NY
01.1999 - 01.2001
First responder to medical emergencies
Assessment of mandatory annual health forms and referrals, including immunization records
Routine administration of medications, including blood glucose monitoring and insulin
Appropriate community referrals, e.g., Health Department, Social Services, and Child Protective Services
Provided health, wellness, and preventative education to students, parents, and teachers
Conducted vision screening and follow-up referrals
Staff Nurse
KEYSTONE CENTER
Leominster, MA
01.1998 - 01.1999
Care of older adults in a long-term setting
Routine medications, assessments, and timely documentation
Compassionate end-of-life care, where I had my first experience with death and dying
Staff Nurse
RIVER TERRACE
Lancaster, MA
01.1997 - 01.1998
Direct patient care to the elderly in a long-term facility with a unique population of Alzheimer's
Sr. Leader Surgical Services Specialty Director at Emory University Hospital & Winship Emory MidtownSr. Leader Surgical Services Specialty Director at Emory University Hospital & Winship Emory Midtown