Review assessments, progress notes, and medical records to formulate a list of concerns and develop a plan of care.
Contact patients to address concerns and identify immediate needs.
Address immediate needs and coordinate referrals to the rest of the Population Health Team. (Pharmacy, Social Work, Community Health Workers)
Responsible for accurate dissemination of medical updates and patients’ needs during team huddle.
Evaluate program data to ensure patient goals are met, monitor for changes in risk levels up or down, timely and successful contact with patients and their families to reduce emergency department visits, and hospital readmission rates and increase patient satisfaction.
Provides education to patients and their families relating to chronic disease management and prevention of complications, medications, and defined treatment plans.
Serve as liaison and facilitated communication between patients, external providers, and Concerto’s Team.
Assess the need for and arrange community-based services.
Identify readmission red flags and discuss this with patients and team members as identified.
RN Case Manager
Concertocare
02.2023 - 12.2024
Provided emotional support to patients coping with chronic illness or end-of-life decisions, fostering resilience during difficult times.
Managed complex cases involving multiple comorbidities, requiring close monitoring and coordination of various healthcare services.
Collaborated closely with physicians to develop individualized treatment plans, supporting optimal patient outcomes.
Educated patients and families on available community resources, facilitating access to necessary support services.
DUKE University Home Care Hospice
10.2019 - 02.2023
Responsible for the care of hospice patients in their homes with terminal diagnoses, focusing on symptom management and risk assessment.
Develop targeted care plans for patients.
Educate patients, families, and caregivers on care, medication management, and prevention.
Collaborate with Hospice Physician for medical interventions.
Orient and assist new team members.
Excela Home Care Hospice
01.2007 - 09.2019
Company Overview: Excela Latrobe Hospital
Provided home care to patients with terminal and cancer-related diagnoses.
Educated patients and families about their diagnosis and future care.
Collaborated with physicians for medical interventions.
Maintained case records and documentation.
Excela Latrobe Hospital
VP, Director– Early Intervention Svc
Dimensions in Health Care, Inc.
12.2000 - 12.2006
Assisted in business strategy development and personnel selection.
Oversaw the daily operation of the company.
Trained and supervised staff.
Managed subsidiary division, Health Care Dimensions.
DIRECTOR, Prism Health Mgt Services
Novaeon, Inc
01.1998 - 12.2000
Company Overview: INTERPOSE
Mentored nursing students.
Managed case management, utilization review, and peer review.
Oversaw staff nurses providing telephonic case management.
INTERPOSE
Skills
Direct patient care
Goal setting
Care coordination
EMR / EHR
Emotional intelligence
Geriatric care
Case evaluation
Patient assessments
Home care management
Staff management
Referral coordination
Patient care planning
Patient counseling
Clinical assessment
Emotional awareness
Palliative care
Case management
Care management
Drug calculations
Home infusion care
HIPAA compliance
Community resources
Medication management
Utilization review
Compassionate and caring
Patient assessment
Attention to detail
Relationship building
Clear patient communication
Monitoring vital signs
Healthcare personnel supervision
Strong clinical judgment
Patient condition monitoring
Vitals monitoring
Procedure assistance
ICD-9 forms
Decision-making
Certification
North Carolina
Commonwealth of Pennsylvania, Professional Nurse, RN-242581L
Ohio, State of Ohio Board of Nursing, 181560, Inactive
Maryland, State of Maryland Department of Mental Hygiene, R155134, Inactive
Maryland, State of Maryland Workers’ Compensation Commission, G1097, Inactive
The Commission for Case Manager Certification, 00055541, 2009
AACN Certification Corporation, 32430, 1987
Professional Committees
Quality Assurance Committee, Excela Health
Task Force for Control of Workers’ Compensation, Construction Association of Pittsburgh, PA
Quality Assurance Committee, Forbes Regional Hospital, Pittsburgh, PA
Standards of Care Committee, Grady Memorial Hospital, Delaware, Ohio
Professional Honors
Nominee Cameo of Caring, 2010, 2011, 2013
Daisy Award, Duke Hospice, 2022
Nominee for the Nursing Excellence Award, Duke Hospice, 2022