Skilled nursing professional with 40 years experience in nursing. Strong background in patient care coordination and healthcare management. Demonstrates expertise in clinical assessment, discharge planning, and patient advocacy. Known for fostering team collaboration, adapting to evolving needs, and delivering meaningful outcomes. Equipped with excellent communication skills, critical thinking, and ability to navigate complex healthcare systems.
Work History
RN/Case-Manger, Social Services
3 Years 11 Months
Grafton City Hospital | 10.2022 - Current
Coordinated comprehensive care plans for diverse patient populations, ensuring adherence to treatment protocols.
Created patient assessments and plans for individual home care needs.
Conducted thorough assessments and evaluations to identify patient needs and develop appropriate interventions for 12 bed acute care unit, including med/surg, psych, swing bed and respite patients.
Monitored patient progress, adjusting care plans as necessary to optimize health outcomes and resource utilization.
Educated patients and families on disease management, promoting self-care strategies and health literacy.
Led case review meetings, mentoring junior staff on best practices in case management and patient advocacy.
Implemented quality improvement initiatives, streamlining processes to enhance operational efficiency within the department.
Analyzed patient data trends to inform strategic decisions and improve overall care delivery effectiveness.
Evaluated patient progress and adjusted care plans accordingly, ensuring continuity of care across all healthcare settings.
Collaborated with physicians and other healthcare providers to ensure appropriate resource utilization for complex cases.
Provided education and support to patients and families, empowering them to make informed decisions regarding their healthcare needs.
Improved patient outcomes by consistently providing comprehensive assessments and developing tailored care plans.
Evaluated healthcare needs, goals for treatment, and available resources of each patient and connected to optimal providers and care.
Streamlined care coordination processes to reduce hospital readmissions and emergency department visits.
Authored initial assessments of patients and family to develop plans for individual home care needs, applying evidence- based guidelines to support appropriate interventions and follow up care.
Conducted comprehensive assessments of patients'' physical, emotional, and social needs in order to develop individualized care plans that facilitated optimal health outcomes.
Enhanced interdisciplinary team communication through regular case conferences, promoting effective collaboration for optimal patient care.
Responded promptly and professionally to patient questions and concerns through proactive monitoring, patient education and advocacy in person and via phone calls.
Advocated for patients by communicating care preferences to practitioners, verifying interventions met treatment goals and identifying insurance coverage limitations.
Effectively communicated with physicians regarding patient needs, performance, medications and changes.
Participated in patient and family planning process, as well as provided instructions and addressed question and concerns about acute and chronic disease management.
Worked with suppliers and vendors on provision of medical equipment, items and services.
Developed professional relationships with community partners to enhance available support services for patients transitioning from acute care settings.
Facilitated interdisciplinary communication among healthcare teams to enhance patient outcomes and service delivery.
RN Waiver/ ACT program
1 Year 5 Months
WVU Medicine United Summit Center | 05.2021 - 10.2022
Med management and direct care of 20 + waiver and multiple ACT clients, from 5 counties. Completes annual assessments, clinical supervision of LPNs and AMAP staff, teaches AMAP certification/recertification classes for med administration, attends and participates in team problem solving, IDT, monthly and annual client meetings, schedules and coordinates client appointments, collaboration with physicians, social workers and other multidisciplinary team members to solve problems and meet care goals.
Collaborated with interdisciplinary teams to optimize patient outcomes and streamline care processes.
Educated patients and families on health management, medication administration, and post-discharge care instructions.
Monitored vital signs and assessed patient conditions, promptly addressing any changes in health status.
Conducted thorough patient assessments to identify changes in condition, promptly notifying physicians and initiating appropriate interventions when necessary.
Skillfully managed challenging patient situations using de-escalation techniques, crisis intervention strategies, and therapeutic communication skills.
Conducted ongoing monitoring and evaluations of behaviors and conditions, and updated clinical supervisors with current information.
Staff Nurse Broaddus Hospital
1 Year 8 Months
Davis Healthcare | 09.2019 - 05.2021
Direct patient care for 15+ patients, including hospice and psych; medication administration, treatments, wound care
Provided direct patient care, assessing and monitoring vital signs for optimal health outcomes.
Administered medications and treatments in compliance with established protocols and safety standards.
Administered medications via oral, IV, and intramuscular injections and monitored responses.
Performed various nursing interventions such as wound dressing, vital sign monitoring, and specimen collection.
Assessed physical, psychological, physiologic, and cognitive status of patients.
Monitored patients' conditions and reported changes in physical presentation, appearance, and behavior to discuss treatment with physicians.
Assistant Director of Nursing, MDS Coordinator
8 Months
Genesis Healthcare | 01.2019 - 09.2019
Collaboration with DON for administrative duties, staff meetings, utilization management, Customer at Risk care planning (CARS), Quality improvement, IDT, clinical leadership and participation in patient goal and re hospitalization evaluations.
Worked directly with MD and NP, taking orders, reporting change in condition. Direct patient care, patient and family education, and supervisory duties. Training for MDS coordinator duties at Salem Genesis. 9 months in managerial position.
Collaborated with interdisciplinary teams to coordinate patient care plans and address complex needs.
Evaluated nursing practices and outcomes to identify areas for improvement and implement best practices.
RN Triage and Staff Nurse
4 Years 7 Months
Fairmont Regional Medical Center Home Health | 06.2014 - 01.2019
Assisted intake coordinator and acted independently when staff was absent to take referrals, perform triage, coding, obtained authorizations for care for medicare, medicaid, VA and private insurance patients, indirect and direct patient care, initial assessments/ triage, collaborated with MD and case managers, discharge planning in Maestro computer system, assists quality assurance program implementation and evaluation, completed chart reviews/ adverse event documentation, scheduled employees, planned and participated in health fairs, marketing, employee competencies and team meetings.
Made home visits, covering 3 different counties, provided direct patient care, chemotherapy administration in the home, and functioned on call.
Educated patients and families on health management and treatment options.
Coordinated with interdisciplinary teams to optimize patient outcomes.
RN Triage and Staff Nurse
11 Years 3 Months
Fairmont General Hospital Home Health | 03.2003 - 06.2014
Assisted intake coordinator and acted independently when staff was absent to take referrals, perform triage, coding, obtained authorizations for care for medicare, medicaid, VA and private insurance patients, indirect and direct patient care, initial assessments/ triage, collaborated with MD and case managers, discharge planning in Maestro computer system, assists quality assurance program implementation and evaluation, completed chart reviews/ adverse event documentation, scheduled employees, planned and participated in health fairs, marketing, employee competencies and team meetings.
Made home visits, covering 3 counties, provided direct patient care, chemotherapy administration in the home, and functioned on call.
Delivered high level of quality care to diverse populations while overseeing patient admission and triaging based on acuity and appropriate department admission.
Collaborated with leadership to devise initiatives for improving nursing satisfaction, retention and morale.
Education
Bachelor of Science - Nursing- BSN
Salem University | Salem, WV | 04-2021
RN- Diploma - Nursing
Washington Hospital School of Nursing | Washington, PA | 06-1981
Skills
Patient care coordination
Case Management
Care plan developement
Patient advocacy
Patient/ staff education
Strong communication and problem solving skills
Utilization review
Chronic disease management
Transitions of care
EMR / EHR
Care coordination
Certification
RN WV Basic Parish Nurse Certificate Present Provide faith based care, volunteer in the community to promote holistic nursing values and education.
BLS/CPR current
Applied for Compact RN license
Interests
I enjoy helping others and giving back to the community
with ongoing participation in healthfairs and community outreach.
Director of Clinical Services/RN Case Manager at Ascension At Home- Together With CompassusDirector of Clinical Services/RN Case Manager at Ascension At Home- Together With Compassus