Annie Perez
Columbia,PA
Summary
Dynamic Care Transition Manager with expertise in post-acute care navigation at Lutheran Senior Services. Proven ability to develop person-centered care plans and advocate for patient needs, ensuring seamless transitions and reducing readmissions. Proficient in EMR systems and skilled in interdisciplinary collaboration, delivering compassionate support to patients and families during critical times.
Overview
4
4
years of professional experience
Work History
Care Transition Manager
Lutheran Senior Services
06.2022 - 02.2025
- Reviewed and processed patient referrals using electronic medical record (EMR) systems to support seamless care transitions and ensure eligibility and service alignment.
- Coordinated discharge planning in collaboration with hospital case managers, physicians, and LSS teams to ensure timely and appropriate placement into skilled nursing, assisted living, or home-based care.
- Conducted clinical assessments and screenings to determine appropriate level of care, considering medical needs, functional status, and payer source.
- Educated patients and families on post-acute care options, services available through LSS, and next steps for ongoing care coordination.
- Facilitated communication between healthcare providers, patients, and families to reduce gaps in care.
- Collaborated with interdisciplinary teams across hospitals, skilled nursing facilities, and home health to develop person-centered care plans.
Medical Social Worker
Wellspan Evangelical
11.2021 - 09.2023
- Conduct comprehensive psychosocial assessments to identify patient needs related to mental health, emotional well-being, support systems, housing, and financial challenges.
- Assist in discharge planning, coordinating services such as home health, rehabilitation, palliative care, or placement in long-term care facilities.
- Advocate for patient needs and ensure that care plans honor patient values, preferences, and cultural backgrounds.
- Provide crisis intervention and supportive counseling for patients and families coping with illness, trauma, or life transitions.
- Collaborate with interdisciplinary teams, including physicians, nurses, and case managers, to develop effective care plans.
- Refer patients to appropriate community resources, including behavioral health, transportation services, support groups, and financial assistance programs.
- Document all interventions and communications in the electronic medical record (EMR) in accordance with regulatory and hospital standards.
Camera Technician
BeTheBeast
01.2021 - 09.2021
- Facilitated smooth transitions between scenes by efficiently disassembling and reassembling equipment as needed.
- Minimized downtime between takes by quickly addressing technical issues or equipment malfunctions.
- Collaborated closely with directors, ensuring alignment in vision and execution of shots.
- Reduced errors on set through rigorous pre-production planning and communication with production team members.
- Supported team efficiency by maintaining organized inventory of camera equipment and accessories.
- Streamlined workflow by managing cables, power sources, and other equipment during shoots.
- Delivered consistent results under tight deadlines without compromising artistic integrity or quality standards.
- Set up equipment for inside and outside shots.
- Set up and operated remote cameras for live video feeds.
Education
Bachelor Of Social Work - Social Services
Bloomsburg University of Pennsylvania
Bloomsburg, PA05.2021
Skills
- Patient discharge planning
- Interdisciplinary team collaboration
- Post-acute care navigation (SNF, home health, rehab, etc)
- Care plan development
- Proficient in EMR systems (eg, Epic, PointClickCare)
- Referral tracking and management
- HIPAA-compliant communication
- Conducting psychosocial assessments
- Providing emotional support and crisis intervention
- Connecting patients to community resources
- Advocating for patient preferences and rights
- Understanding of Medicare, Medicaid, and managed care
- Familiarity with hospital and post-acute workflows
Timeline
Care Transition Manager
Lutheran Senior Services
06.2022 - 02.2025
Medical Social Worker
Wellspan Evangelical
11.2021 - 09.2023
Camera Technician
BeTheBeast
01.2021 - 09.2021
Bachelor Of Social Work - Social Services
Bloomsburg University of Pennsylvania