Gail Roberts

Patient education on chronic kidney disease and associated comorbidities.

• Identified potential barriers to care, implementing tailored solutions to improve outcomes.
• Maintained detailed documentation of patient interactions, treatment plans, and progress notes for accurate recordkeeping.
• Conducted comprehensive assessments of patient needs, developing individualized care plans accordingly.
• Educated member on gaps in care and assisted with scheduling provider appointments.
• Assisted members with social determinants of health and linked to appropriate community resources.
• Consistently maintained confidentiality while handling sensitive patient information in accordance with HIPAA guidelines.
• Advocated for patients'' best interests when working with insurance companies or other external entities involved in their care process.
• Participated in regular team meetings, huddles, staff meetings and quality improvement projects to improve patient care.

• Authored initial assessments of patients and family to develop plans for individual home care needs.
• Worked with suppliers and vendors on provision of medical equipment, items and services.
• Took active role in patient and family planning process, detailing instructions and responding appropriately and effectively to questions and concerns.
• Responded promptly and professionally to patient questions and concerns.
• Coordinated with interdisciplinary professionals to develop plans of care, administer tests and monitor patient status.
• Developed professional relationships with community partners to enhance available support services for patients transitioning from acute care settings.

• Reduced care costs without sacrificing quality through effective service coordination and multidisciplinary collaboration.
• Participated in patient and family planning process, as well as provided instructions and addressed question and concerns.
• Identified care needs of individual patients and coordinated responses based on physician advice, insurance limitations and procedural costs.
• Worked with suppliers and vendors on provision of medical equipment, items and services.
• Conducted utilization reviews with the used of InterQual and MCG to gauge medical necessity.
• Collaborated with the multidisciplinary team, patients and family members to develop safe discharge plans.
• Facilitated smooth transitions between healthcare settings by effectively communicating pertinent information to receiving facilities or home health agencies.

• Led shift handover meetings effectively communicating critical information about each patient''s status ensuring continuity of care.
• Coordinated nursing care on unit through staff assignments, assisting and rounding with physicians, monitoring patient orders, and communicating with ancillary departments.
• Collaborated with interdisciplinary teams during rounds, providing input and advocating for patient needs.
• Conducted daily shift briefs to inform staff of changes in patient care assignments.
• Quickly responded to situations impacting safety and security to unit, actualizing crisis prevention interventions to control and de-escalate situations.
• Delivered high level of quality care to diverse populations while overseeing patient admission and triaging based on acuity and appropriate department admission.