Amy Smith

• Coordinated care plans with multidisciplinary teams to support patient needs.
• Assessed patient health status and identified necessary interventions for improvement.
• Educated patients and families on managing their chronic health conditions.
• Documented patient progress and updates in electronic health record systems.
• Facilitated communication between patients, providers, and community resources.
• Developed personalized care strategies to enhance patient engagement and compliance.
• Created plan of care to assist patients in reducing problems or barriers to achieve optimal level of health.
• Monitored adherence to care plans and adjusted strategies as needed.

UPMC Health Plan D-SNP program served over 44,000 D-SNP members throughout Pennsylvania.

• Participated in the Interdisciplinary Care Team (ICT), presenting complex patients and collaborating with other nurses, social workers, physicians, and other care team members in a patient-centered approach.
• Conducted Health Risk Assessments (HRA) with member outreaches and incoming calls.
• Created an Individual Care Plan (ICP) based on HRA to assist members in managing their medical and behavioral health conditions.
• Responsible for reducing problems or barriers to achieve an optimal level of health at the lowest cost and level of care.
• Ensured that all documentation was completed accurately, according to state regulations.

Telephonic nurse care manager following high-risk patients assigned to medical groups within Providence Health & Services in Southern CA, including D-SNP and Cal Medi-Connect populations. Managed patients with chronic medical and behavioral health conditions, helping to coordinate multiple services and resources, providing education, and identifying and removing barriers to care. Utilized health risk assessments, individualized care plans and collaborated with interdisciplinary care team.

Clinical nurse on the Advanced Primary Stroke Unit, responsible for the safe, therapeutic, and efficient care of patients with stroke, neurovascular, cardiac, pulmonary, renal, and endocrine pathologies. Care goal was to ensure the optimum outcome from hospital to discharge. Comprehensive oral and written communication with physicians and other medical staff to provide enhanced patient-centered care.