Responsible for the overall care management of patient panel
Establish trusting relationships with patients and families to provide clinical and emotional support and foster collaboration throughout their care journey.
Serve as an advocate for patients to ensure proper and timely resources and support
Perform assessments and identify the needs of patients and caregivers based on values, care goals, and individual preferences, and translate these into patient centered, actionable care plans
Coordinate the interdisciplinary approach to achieve continuity of care.
Monitor and evaluate the effectiveness of care management plans regularly, modifying interventions as necessary
Collaborate with physicians, APPs, and other clinical disciplines to create, implement and manage integrated care plans
Identify cost-effective measures for patients that support care goals of improving patient outcomes and quality while effectively managing resource utilization.
Facilitate patient and caregiver education
Support seamless transitions of care as patients move between care settings, proactively addressing barriers and collaborating with IDTs.
Actively participate in clinical huddles and patient care conferences
Collecting data to prepare and deliver reports on patient outcomes and patient/caregiver satisfaction
RN Case Manager
Landmark Health/Optum
Harrisburg, PA
10.2022 - 09.2024
Responsible for clinical operations and medical management activities across the continuum of care from assessing and planning to implementing, coordinating, monitoring and evaluating a large panel of patients
Provide health education, coaching and treatment decision support for member
Make outbound calls to assess member’s current health status
Identify gaps or barriers in treatment plans
Provide patient education to assist with self-management
Interact with Medical Directors on challenging cases
Coordinate care for members and services as needed (home health, DME, etc.)
Educate members on disease processes
Encourage members to make healthy lifestyle changes
Make calls post-discharge to ensure that discharged members receive the necessary services and resources
Document and track findings
Wellness Nurse
SpiriTrust Lutheran
Shrewsbury, PA
05.2020 - 10.2022
Assess and screen independent living residents
Organize and facilitate educational presentations
Serve as a liaison and a resource to clientele
Organize Wellness Fair. Chair utilization review committee
Assist residents with navigating healthcare
RN Supervisor
SpiriTrust Lutheran
Shrewsbury, PA
08.2003 - 05.2020
Supervise RNs, LPNs and CNAs. Ensure nursing operational standards are met
Provide reports on productivity, quality and customer service metrics
Ensure all nurses follow policies and procedures
Train new team members
Evaluate nurses’ performance
Inform family members about medical procedures and doctors’ instructions
Handle complaints or other issues
Establish a compassionate environment by providing psychological support to patients, family, and friends
Evaluate patients and report to MD
Initiate and update care plans
Collaborate with interdisciplinary team to provide highest quality of care to patients
Performed RNAC duties including: scheduling and completing assessments, care plans, team meetings, audits, reporting significant changes, and discharge planning
Acted as Infection Control Nurse and ADON as needed
School Nurse Substitute
Southern York County School District
Glen Rock, PA
09.2012 - 01.2014
Assess students with injuries or illness
Administer medications
Treat minor injuries
Review medical history
RN Charge Nurse
Stella Maris
Timonium, MD
10.1997 - 10.2002
RN charge nurse supervising dementia unit.
RN staff nurse on skilled unit
Provided bedside care
Phone intake
Monitored and documented patient's vitals
Provided daily medication administration and administration of all medications
Treated life-threatening emergencies
Patient education
Carried out the care plan planning
Provided discharge planning
Consulted and coordinated with healthcare team members
Facilitated the plan of care
Demonstrated leadership skills
RN Supervisor
Genesis Multi-Medical Center
Towson, MD
01.1997 - 03.1998
Assessed patient physical, social, language or mental needs
Maintained patient records
Medication administration including narcotics and intravenous therapy
Delivered patient education
Developed and managed treatment plans
Provided discharge planning
Consulted with physicians
Facilitated the plan of care
Performed direct clinic nursing administrative duties
Demonstrated leadership skills
RN
Hazleton St. Joseph Medical Center
Hazleton, PA
10.1994 - 12.1996
Provided direct nursing care for up to 8 patients per shift
Performed patient assessments
Monitored, recorded and communicated patient condition
Administered oxygen and blood products
Provided life-saving interventions
Able to plan and implement individualized teaching and advice to patients
Developed and managed treatment plans
Developed and implemented discharge plans
Assisted physicians
Directed or supervised less-skilled nursing or healthcare personnel
Trained new staff
Education
Associate in Nursing -
Luzerne County Community College
05.1994
Skills
Case Management
Nursing Home
Home Health
Home Care
Dementia Care
Nursing
Employee Evaluation
Medication Administration
MDS
Hospital Experience
Proficiency in multiple EHRs
Epic
DocTalk
Powerchart
Health Gorilla
Allscripts
Zus
Dhin
PointClickCare
Crisp
Certification
RN License, PA (Multi-State/Compact), DE, VA, NY, NJ