Claudia Sofia Moreno

Conduct comprehensive assessments on clients' needs and develop individualized care plans.

Maintain accurate and timely documentation of client progress and interactions and upload to CJAMS.

Coordinate and participate in case conferences and multidisciplinary team meetings.

Advocate for clients access to resources such as housing, health care, and financial assistance.

Monitor and evaluate the effectiveness of service plans and make adjustments as needed.

• Completed needs assessments for patients and their families related to the adjustment of illness, disability, critical care issues, acceptance of discharge recommendations, need for long-term care placement, end of life, grief, trauma, abuse and neglect, substance abuse, and mental health issues.
• Provided transition of care strategies in complex situations such as: substance abuse, psychiatric, or dual diagnosis placement/services, ventilator dependent patients, inpatient dialysis services, patients with no insurance needing skilled nursing facility placement, patients requiring guardianship, long term/custodial placement.
• Identified community services and resources available to patients and families and facilitated linkage with those services.
• Collaborated with the interdisciplinary team and communicated the progress and status of referred patients.
• Ensured timely, appropriate, and accurate evaluation and reporting of suspected child/elder abuse and or neglect.
• Documented interventions in patient's medical record following department standards.
• Enhanced interdisciplinary team collaboration for optimal patient care through regular case conferences and communication.
• Collaborated with medical professionals to advocate for the unique psychosocial needs of each patient within a holistic care approach.
• Educated patients on available treatment options and assisted in informed decision-making regarding their healthcare plan.

• Provided expert technical assistance and guidance related to affiliate service provision challenges, community engagement, and client inquiries as it relates to all ORR funded programs
• Represented Global Refuge during meetings with external stakeholders
• Conducted desk and on-site monitoring for all partner agency providers, including reviewing case physical files and personnel files
• Conducted individual interviews with program staff and clients to ensure compliance with all ORR policies and procedures
• Conducted weekly meetings with ORR partner agencies to monitor trends, or issues that might impact program operations and State and Federal compliance
• Evaluated the data collected during monitoring and write reports to detail the outcomes of the monitoring visits
• Requested corrective action plans from sites as necessary and support improvement plans
• Compiled programmatic analytical data to conduct statistical reports to submit to ORR
• Completed quarterly and annual performance reviews for existing and new programs to report to ORR
• Provided training and technical assistance to internal staff and external partners
• Remained knowledgeable of complex mental health/trauma, medical, safety, and juvenile justice issues that impact children who are referred for foster care
• Provided ongoing case and programmatic consultation to Global Refuge's residential therapeutic programs, federal staff, and other stakeholders (i.e
• Child advocates, attorneys, etc.)
• Lead collaboration efforts with Foster Care partners engaged in service provision to unaccompanied children
• Responsible for network coordination, communication, and peer learning throughout the network
• Provided support and technical assistance to partners related to issues of service delivery, documentation, reporting, Global Refuge, and Child Welfare best practices, as well as Federal obligations
• Provided ongoing desk and onsite monitoring to Foster Care Partners to assess program functioning and compliance with State/ORR/Global refugee standards, as well as to identify trends, and service gaps, and evaluate service models
• Identified training needs and program challenges, for the development of materials, resources, and tools to enhance the delivery of program services in accordance with recognized child welfare standards, Global Refuge best practices, and Global Refuge/ORR Policies and Procedures implementation
• Oversaw a team of Program Officers and complete weekly supervision meetings
• Built strong relationships with stakeholders through effective communication and collaboration.
• Analyzed project performance data to identify areas of improvement.
• Mentored Program Officer staff members to enhance their professional growth and contribute to overall team success.

• Ensured program operations and services were consistent with the established agency, state (COMAR), federal, and licensing standards and requirements
• Ensured agency policies and procedures are enforced through completion of staff evaluations, conference requests, time sheets and reimbursement vouchers
• Maintained, enhanced, and developed positive relationships with stakeholders, community agencies, and community progressions
• Reviewed all incidents, releases, and case reporting expectations to satisfy federal, state and agency requirements as well as for areas of program improvement
• Addressed audit findings through corrective action plan Directed and trained all clinical and case managing staff, if neede
• Instructed staff on identification and proper procedures for completion of significant incident reports (SIRs), that are the result of child abuse and neglect
• Cultivated a trauma-focused environment where program staff model positive adult behaviors, while also nurturing youth and providing structure, support, respect, and active involvement to unaccompanied children (UC)
• Oversaw training curriculum and compliance to include but not limited to the CPI program, UC training, First Aid/CPR, and new employee orientation
• Collaborated with intake and referral teams to ensure appropriate capacity and placement of youth in programs to ensure housing and care of UC
• Audited and oversaw the appropriate aftercare and transitions post placement
• Participated in speaking engagements, courses and learning experiences, when necessary.
• Responsible for interviewing and hiring staff to fill agency vacant positions.
• Performed assessments of proficiency level, in Spanish for prospective staff
• Identified translation service providers to assist in translation with clients from diverse backgrounds
• Coordinated with internal educational, clinical, medical, and case management teams to ensure compliance with ORR policy to ensure for the safe and timely release of minors
• Updated for UC specific needs and ensure mental and physical health, develop introduction English and second language skills, and delivered completed cases for release
• Stayed abreast of all federal and state regulatory requirements related to social services

• Maintained an awareness of current trends and relevant evidence-based practices
• Conducted weekly group therapy sessions twice per week with clients in the program
• Conducted weekly individual sessions with clients or as outlined in the therapeutic treatment plan
• Completed and reported on client intakes, closing summaries, and psychosocial documentations in a timely manner and in accordance with agency standards
• Provided reports and testimony in court, as requested
• Administered the intake psychosocial assessment within 24-48 hours of client's arrival to the program
• Administered the trafficking assessments within the defined number of days of the client's arrival to the program
• Provided additional counseling sessions with children and their families either by phone or Skype, as needed, to assist in the reunification process
• Attended meetings with the treatment team and actively participate in meetings
• Met weekly with the Program Coordinator and/or Program Manager to share updates on client's progress
• Attended training provided internally and in the community and apply newly gained knowledge in providing services
• Translated both written and verbal communication for program clientele and staff
• Attended weekly meetings with clinical supervisor to consult on cases, to review case plan and direction, and to evaluate client participation and progress
• Maintained clear and concise documentation of treatment efforts
• Effectively utilized appropriate systems for data gathering, submission, and tracking client services rendered in accordance with time-bound expectations based on contract requirements, agency expectations, and program policy
• Established and maintain referral and community resources
• Coordinated outside professional consultations, to include psychiatric and psychological when needed while ensuring documentation for consultations is completed in a timely and effective manner
• Conducted trafficking assessments and education as needed
• Maintained electronic and hard copy client files in areas of case notes, assessments, progress reports, and more in a timely manner
• Collaborated with intake and referral teams to ensure appropriate capacity and placement of youth in programs

• Oversaw case reunification process and ensure compliance with ORR (Office of Refugee) policy and procedure and state policy and procedure in every case
• Assist in the development, update and maintenance of program operating manuals
• Maintained, enhanced, and developed positive relationships with referral sources, state and federal agencies, volunteer and community agencies, employers and individuals
• Managed intake and referral processes for unaccompanied children coming into care.
• Completed Significant Incident Reports upon disclosure of physical, verbal, or sexual abuse by the minor or as reported by sponsor or third party
• Conducted initial assessments for unaccompanied children admitted to the program and determined risk factors while assessing history of trauma
• Developed Individualized Service Plans to meet the needs of the minors at the program
• Provided program education to the minors entering the program and individuals seeking to sponsor a minor
• Translated information to sponsors to facilitate an understanding of policy and procedures
• Engaged with in a culturally sensitive manner to foster an environment of acceptance and support
• Provided weekly updates to the minor, sponsor, foster parents, and the staff overseeing the case
• Obtained and verified information provided by minors entering the program and information provided by Sponsor by interviewing friends and family in home country
• Assessed need to conduct TVPRA home studies or Discretionary Home Studies
• Presented release recommendations to the case coordinator, Federal Field Specialist, and Contract Federal Specialist during weekly case staffing
• Developed Safety Plans when concerns arise regarding the transition of the minor post release
• Completed Case Reviews for every 30 days that a minor has been in the program
• Attended local and national meetings that will enhance provision of services to refugees
• Delegated priorities to the case support staff to ensure compliance with deadlines
• Traveled as needed to ensure timely release of the UC
• Complied with deadlines and reports according to ORR policy
• Conducted interviews, screenings, assessments, home visits, post placement support/reports and home studies as needed
• Managed case files such as reports, client notes, and other pertinent material relevant to the case
• Documented all contacts appropriately in client case record
• Maintained case documents updated in UAC Portal
• Conducted assessments for individuals seeking sponsorship of unaccompanied minors
• Assisted families in obtaining post release services to assist during the post reunification phase

• Provided direct client care in 1:1 setting utilizing a combination of intensive teaching and natural environment training arrangements
• Followed the prescribed behavioral skill acquisition and behavioral reduction protocols
• Collected, recorded, and summarized data on observable client behavior
• Assisted with parent and caregiver training in line with client’s individualized treatment and behavior reduction protocols
• Effectively communicated with parents and caregivers regarding clients’ progress
• Translated treatment plans and educational material in Spanish to facilitate parental engagement

• Followed programs mission to support and provide options to people with disabilities
• Aided clients with significant disabilities at risk for being institutionalized
• Encouraged clients with disabilities to realize their power by providing education on community resources and their rights to obtain these resources
• Assisted in processes to allow clients with disabilities receive in-home services approved by Medicaid
• Facilitated in the transition of clients with significant disabilities from nursing homes and other institutions to home-based settings
• Assisted consumers with housing issues, including but not limited to obtaining affordable and/or accessible housing, accessing funding to pay for accessibility modifications, communication with public housing agencies
• Assisted consumers in identifying goals and implementing individualized treatment plans
• Facilitated timely completion of Independent Living Plans or goals
• Provided individual advocacy to compliment consumer self-advocacy when needed and appropriate
• Entered consumer and community goals, services and activities in the agency database as needed
• Assisted the program director in agency events to facilitate community engagement in the Prince William county, Fauquier county, and cities of Manassas

• Assisted in birth parents in achieving requirement established in family court
• Assisted case worker in coordinating services and ensuring needs of children are being met in foster care
• Provided guidance and support to foster parents
• Assisted in the formulation of progress notes, family assessments, service plans necessary for court reviews

• Assessed patient/family social and emotional factors in order to estimate their ability to cope with terminal illness and death
• Provided psychosocial counseling and support to the patient/family experiencing emotional, social and economic conflict
• Assisted patient/family and staff in utilizing community services
• Participated in interdisciplinary team (IDT) meeting to establish, review and revise the plan of care for each patient, including exchange of information, review of problems, and sharing of professional support
• Assisted in the maintenance of electronic medical records, assuring accuracy, completeness and compliance with regulations, legal and ethical standards
• Identified and addressed comfort care needs in collaboration with other members of the Homecare team
• Support, instruct and educate the patient, family, and caregiver
• Coordinated all patient and family services
• Maintained the dignity of the dying patient
• Supported the patient's and family's unique spiritual and cultural beliefs

• Processed medical claims and updated internal database in the computer
• Handled various insurance verification and authorization management functions
• Documented all communication with insurance carriers to effectively process pre-certifications for inpatient/outpatient hospital procedures
• Handled the tasks of verifying insurance coverage by phone, online or through electronic systems
• Handled the tasks of educating patients regarding third party collection program
• Responsible for answering patients' questions on insurance coverage plans
• Handled the tasks of preparing and maintaining patient insurance information in the data system
• Handled and resolve patients phone calls concerning insurance claims and issues
• Responsible for maintaining the DD2569 program to document and verify insurance coverage for all patients seeking care in the military facility
• Billed third-party payers on behalf of beneficiaries for treatment provided by or through military treatment facilities
• Established procedures to identify patients with other health insurance and to submit and follow up on claims to other health insurance provider
• Retrieved patient information from programs such as Essentris, AHLTA, CHCS, and TPOCS to effectively bill third party insurances

• Conducted psychosocial evaluations on incoming patients (approximately 40-50 patients)
• Lead group therapy and individual counseling sessions under authorized supervision
• Documented and update patient charts
• Presented internship experiences and findings to upper-level psychology students
• Learned and evaluated new techniques for dealing with emotional and environmental problems
• Participated in crisis interventions as necessary
• Assisted in the formulation of treatment plans utilizing various modalities of treatments
• Provided consultation, education, and information services to lay and to individuals