Dynamic RN Case Manager with extensive experience in end of life care, excelling in chronic illness management and patient care coordination. Proven track record of reducing hospital readmissions through effective case management and empathetic support. Skilled in cross-functional collaboration, developing comprehensive care plans, and fostering strong relationships with patients and families.
Professional with strong background in nursing and case management, specializing in patient advocacy and care coordination. Adept at developing comprehensive care plans, managing complex medical cases, and working collaboratively with multidisciplinary teams to achieve optimal patient outcomes. Known for adaptability, reliability, and results-focused approach in dynamic healthcare environments. Skilled in patient assessment, discharge planning, and resource utilization.
Review hospice referrals, discuss care options with patients and families, assess for eligibility for hospice based on Medicare guidelines.
Assist hospital case managers to ensure safe discharge of hospice patients
Provide education and coordination between hospice and community referral resources which includes physicians, hospital staff, health facilities and community based health programs
Customer service and timely follow up on patient, family or facility concerns.
Instructing new employees on admission process and eligibility criteria
Frequently provide ongoing education to facilities relating to hospice practices and symptom management for patients at end of life.
Assumed overall responsibility for hospice patients
Communication between physicians, staff members and agencies to coordinate care for patients
Assessed, planned, implemented, reevaluated and revised plan of care as need to meet patient and family needs
Assessed physical, psychological, spiritual and social issues
Provided direct patient care and education to caregivers
Effectively supervised 5 LPN's, 5 RN's and 3 CNA's
Responsible for organizing and directing care to meet patient, staff and family needs.
Assessed need for, ordered, obtained and interpreted appropriate labs and tests
Patient care in post op setting
Adeptly handling aspects of treatment from medication to pain management
Primary care, assessment and evaluation of post op patients.
Various positions throughout the hospital including Med-Surg, Rehab, Oncology and outpatient clinic