ANGELICA ALBARRAN
Kenosha,USA
Summary
Currently working as an RN Care coordinator at KCHC/PILLAR. I am assigned to 3 providers. My role as Nurse coordinator is assisting in supporting the management of patients panel using proactive and planned care goals while also coordinating the care team necessary to achieve them. The RNCC participates in the delivery of evidence-based care to an assigned patient population utilizing defined care standards, identifying care gaps, ensuring efficient access to care, care planning, and facilitating seamless care transitions and care continuity. The RNCC also participates in the analysis of outcomes, identification of opportunities for improvement, and implementation of changes to optimize outcomes for individual patients and the overall population. The RNCC responsibility is to facilitate an inter-professional team of clinicians in a wraparound care coordination model that will identify and address patient emergent, chronic, preventative care and social needs, placing patients in the best position for optimal health outcomes.
Overview
20
20
years of professional experience
Work History
RN Care Coordinator
KCHC/PILLAR
Kenosha, USA
02.2024 - Current
- Assisting in supporting the management of patients panel using proactive and planned care goals while also coordinating the care team necessary to achieve them.
- Participates in the delivery of evidence-based care to an assigned patient population utilizing defined care standards, identifying care gaps, ensuring efficient access to care, care planning, and facilitating seamless care transitions and care continuity.
- Participates in the analysis of outcomes, identification of opportunities for improvement, and implementation of changes to optimize outcomes for individual patients and the overall population.
- Facilitates an inter-professional team of clinicians in a wraparound care coordination model that will identify and address patient emergent, chronic, preventative care and social needs, placing patients in the best position for optimal health outcomes.
- Reviews and assesses patient registration data, including outpatient or inpatient treatments, emergency room visits, medications, chart reviews, to assist in the monitoring and facilitation of adherence to prescribed care plans.
- Using (EHR) and other electronic resources to identify patient care gaps and coordinate activities with the provider and care team to close those gaps.
- Utilizes organization defined risk stratification tools, EHR, and other electronic resources to risk stratify the assigned patient panel and track indicators of the panel.
- Chronic Care Management of medium, rising risk and high-risk patients.
- Draw conclusions from available data to develop an overall strategy for the assigned patient panel, and individual patients in the different risk groups.
- Routinely evaluates social needs that can negatively impact health outcomes. Connects patients to available resources to meet those needs.
- Initiates or contributes to the development and implementation of individualized, comprehensive care plans including medical and social needs.
- Accesses internal and external resources to support development and implementation of the individualized and patient centered care plan.
- Facilitates patient understanding of the practitioner’s treatment plan, including but not limited to, prescriptions, refills, medical supplies, referrals, patient education, and when to seek care.
- Assists clinic and providers to meet efficiency, patient throughput, and productivity targets by serving as the clinical lead in a team-based approach to patient care.
- Uses reporting tools in the EHR and other electronic resources to monitor quality metrics and develop a plan with the provider and care team to implement improvements.
- Direct or telehealth patient education/coaching to improve health outcomes and achieve individualized patient goals.
- Coordinates internal and external Transitions of Care.
- Demonstrate leadership within delegation of duties and supervision to ancillary staff.
- Directs medical support and ancillary staff to ensure efficient patient throughput and an on-time patient schedule.
- Participates in onboarding, competency validation, and evaluation of medical support and ancillary staff.
- Participation in practice committees and task forces to ensure the implementation of standardized, evidence-based practice tools and educational materials to ensure consistency across the practice.
- Always maintains patient confidentiality and follows all HIPAA guidelines and regulations.
- Participate in scheduled Quality Indicators (QI) Committee meetings, including QI activities relative to grant related requirements.
- Communicates the clinic’s results on QI indicators to clinic staff & participates in action plan development.
- Solicits feedback from the clinical team including suggestions for action plans, barriers, etc. and relays them to the QI Committee.
- Actively participates in daily huddles to plan activities and resources for the day.
- Participates in pre-visit planning activities with assigned provider, PCP, and other care team members.
Registered Nurse Palliative and Hospice Admissions
Hospice Alliance
Pleasant Prairie, USA
08.2014 - 02.2024
- Admission RN, Case Management, Visit RN and coordination of care of all patients.
- Hospice and Palliative RN plan and deliver care to patients utilizing the nursing process of assessment, planning interventions, implementation and evaluation, and effectively interacting with patients, families and interdisciplinary team members while maintaining standards of professional nursing and clinical competency.
- Visits/assignments made are directed and guided by RN leading the shift, Perform consultations and admissions to assess patient's needs, complete admission assessment, contractual agreements and necessary documentation.
- Conduct routine and emergent visits to Hospice and Palliative care patients.
- Travel to the patients place of residence to conduct visit/admission.
- Responsible for assessing a patient's medical status, planning, teaching, and implementing immediate medical interventions on day of admission.
- Complete medical reconciliation, coordinated medications- standing orders and DME needs at time of admission.
- Collaborates with an attending physician. Hospice medical director, NP, director of operations, Social worker, and other involved personnel regarding the patient's admission and follow up needs.
- Performs timely administrative functions and documents all patient's information in a timely manner.
- Provides detail report to IDT: CMRN, SW, Chaplain and CNA.
Registered Nurse Team Lead 1W - MDS Coordinator
Ridgewood SNF
01.2013 - 08.2015
- Responsible for unit (1 west) monitor and report significant changes in patient condition to PCP.
- Assign and coordinate responsibilities with unit staff, RN, LPN and CNAs.
- Delegate medication administration, wound treatments and cares to LPNs and CNA.
- Document patient care provided throughout the shift.
- Administer daily medications and treatments per physician’s order.
- Provide emotional support to patients and families.
Legal Secretary
SHAW LAW, LTD.
05.2008 - 01.2013
- Provide high-level administrative support to Owner.
- Perform a variety of functions, addressing inquiries of current and potential clients, communicating with staff, clients and/or opposing counsel regarding status of cases.
- Assist attorneys drafting legal documents (Criminal, family, bankruptcy and forcible matters).
- Responsible for the collection department.
Realtor - License on hold
PRUDENTIAL
02.2008 - 01.2009
Property Manager
FOREVER CONSTRUCTION
Waukegan, USA
10.2005 - 05.2008
- Provide high-level administrative support to Owner.
- Perform a variety of functions, addressing inquiries of current and potential tenants and/or buyers, coordinate appointments, communicating with staff regarding maintenance, and maintaining tenants’ databases.
- Receive phone calls & return calls from prospective tenants/buyers.
- Schedule appointment for apartment showings & showing of apartments/condominiums.
- Screen application – per management’s qualifications and fair housing requirements.
- Move in new tenants, including lease signing, move in inspection & collection of deposit.
- Work with current tenants.
Education
Central Valley High School
Yuba City, CASkills
- Care coordination
- Patient assessment
- Chronic care management
- Electronic health records
- Evidence-based practice
- Health education
- Case management
- Quality improvement
- Risk stratification
- Treatment planning
- Effective communication
- Team collaboration
- Problem solving
- Leadership development
- Adaptability
- Basic life support
- Cultural history
- Research utilization
- Compassion and empathy
- Nursing informatics
- Health promotion
- Clinical judgment
- Community health
- Discharge planning
- Geriatric care
- Advanced cardiac life support
- Documentation and charting
- Patient management
- Chart updating
- Administering immunizations
- Team coordination
- BAC screening/drug screen collection
- Mobility assistance
- Patient satisfaction and process improvement
- Precepting
- Operating room skills
- Personal care needs
- Medication administration
- Patient monitoring
- Reporting and documentation
- Health screening
- Call triaging
- Stress mitigation
- Data collection
- Trauma recovery
- High level of autonomy
- Disease specialization
- Medical screening
- Patient consultation
- Evaluations
- Supply restocking
- Geriatric treatment
- Health and wellness expertise
- Spanish proficiency
- Medical office administration
- Complex Problem-solving
- Direct and indirect patient care
- Patient counseling
- Tracheostomy care
- Professional bedside manner
- Family and patient support
- SBAR communication
- Patient relations
References
Available upon request.
Timeline
RN Care Coordinator
KCHC/PILLAR
02.2024 - Current
Registered Nurse Palliative and Hospice Admissions
Hospice Alliance
08.2014 - 02.2024
Registered Nurse Team Lead 1W - MDS Coordinator
Ridgewood SNF
01.2013 - 08.2015
Legal Secretary
SHAW LAW, LTD.
05.2008 - 01.2013
Realtor - License on hold
PRUDENTIAL
02.2008 - 01.2009
Property Manager
FOREVER CONSTRUCTION
10.2005 - 05.2008
Central Valley High School