Summary
Overview
Work History
Education
Skills
Certification
Timeline
Generic

Graciela Morales

Cranston,RI

Summary

Proficient working within population health management/ value based care programs, preferably those delivered by ambulatory/community health plans. Strong organizational skills including development of project workflows, program re-development and timelines and outcome measurement. Experience working with multi-disciplinary teams and stakeholders. Expert in PowerPoint, Microsoft Office, Power BI, Practice Analytics, Care Message and Intergy EHR. Detail oriented with strong organizational skills. Skilled at developing diversity, equity, and inclusion. Authorized to work in the US for any employer Professional Patient Navigator with 6 years of experience working with medicaid and medicare patients. Committed to long-term patient support and comprehensive education. Successful at patient advocacy and breaking through barriers with clients. Health Navigator collaborates with members of health care team to develop medically appropriate and cost effective care initiatives to assess and coordinate chronic disease care management for patient population. Strong analytical and data management skills to exercise clinical judgment in interactions with physicians, payers, patients and families. More than [Number] years of nursing experience, utilization review and discharge planning expertise to make critical decisions.

Overview

12
12
years of professional experience
1
1
Certification

Work History

Senior Patient Navigator

The Providence Community Health Centers, Inc
03.2023 - Current
  • Monitor and support data collection and management pertinent to population health
  • Provide technical assistance as directed to collaboration partners
  • Serve on project work groups and subcommittees as assigned by Director of Population Health
  • Project planning, including, but not limited to, alignment to corporate strategy, definition of scope, resources, budget, and overall implementation strategy
  • Leveraging analytical knowledge and team leadership skills, drive development of analytical solutions and implement data-driven recommendations and outcomes
  • Support study team activities, generate reports, operating review meetings, and management requests through delivery of information to support performance progress
  • Provide administrative support to Manager, AE Patient Navigators and other staff within AE
  • Department
  • Provide coaching and mentorship to AE Patient Navigators and other staff within AE Department
  • Provide coverage when AE Patient Navigators and other staff are out on vacation, medical leave or at capacity
  • Assists staff with complex patient issues
  • Oversee orientation/training of new AE Patient Navigators and other team members
  • Developing new training materials for new staff
  • Works with all members of Health Care Team and Accountable Care and Population Health team to significantly improve patient outcomes in quality and primary care engagement
  • Demonstrates knowledge of goals and objectives of PCHC’s Accountable Care and Population Health strategies, and proficiency in engaging patients to help close care gaps of all kinds
  • Support Population Health by completing centralized patient assessments and screenings, and associated administrative order entry, documentation, and other tasks
  • Performs clinical activities under direction of supervising medical professional where appropriate, including clerical work, medication reconciliation, screening questionnaires, chart preparation, entering data into medical records, and executing standing orders, outreach, and visit planning
  • Uses approved tools, to outreach to various cohorts of patients, address gaps in care, and generate reports for internal and external stakeholders
  • Provide general clerical support including, but not limited to, filing, answering/rerouting calls, and
  • Electronic Health Record functions according to PCHC Policy & Procedures
  • Assist patients with their needs including, but not limited to, providing education to patients with open care gaps, coordinating referrals and scheduling appointments to complete and address open care gaps, understanding how to access care appropriately, how to access community resources, and how to address barriers to care
  • Schedule patients using accepted appointment scheduling protocols
  • Assists in ensuring that digital faxes, scanning mail and other external communication are correctly handled, documented and attached to open orders in electronic medical record where appropriate
  • Manages patient data collection via work queues, databases, and electronic health record
  • Assists with data collection for daily, monthly, quarterly, and annual reports
  • Work independently to maintain detailed, timely, accurate records and documentation, including accurately and effectively documenting patient interactions in Electronic Health Record
  • Always maintains confidentiality with respect to HIPAA standards and, when needed, CFR42 Part 2:
  • Protecting patient’s rights to confidentiality and privacy, including but not limited to health records, and other medical correspondence reports
  • Support PCHC’s mission, vision, and values with focus on customer relationship management and satisfaction in all interactions with patients, visitors, providers and staff with understanding and sensitivity to age, spiritual and cultural diversity
  • Demonstrates professional conduct through appropriate communications, respect and courtesy to all individuals
  • Represents organization with positive, professional attitude at all times
  • Performs other duties as assigned.
  • Participated in regular team meetings, huddles, staff meetings and quality improvement projects to improve patient care.
  • Consulted with medical staff and ancillary department to eliminate barriers to delivery of care and identified service delivery problems and potential for patient management intervention.
  • Assisted patients in scheduling doctor and healthcare appointments.
  • Organized patient schedules and assisted in planning transportation.
  • Followed document protocols to safeguard confidentiality of patient records.
  • Facilitated communication between patients and various departments and staff.
  • Resolved customer complaints using established follow-up procedures.
  • Answered incoming calls, scheduled appointments and filed medical records.
  • Applied administrative knowledge and courtesy to explain procedures and services to patients.
  • Responded to inquiries by directing calls to appropriate personnel.
  • Compiled and maintained patient medical records to keep information complete and up-to-date.
  • Worked with patients to ascertain issues and make referrals to appropriate specialists.
  • Trained new staff on filing, phone etiquette and other office duties.
  • Recommended service improvements to minimize recurring patient issues and complaints.
  • Delivered support to medical staff in completion of patient paperwork.
  • Engaged with patients to provide critical information.
  • Helped address client complaints through timely corrective actions and appropriate referrals.
  • Organized patient records and database to facilitate information storage and retrieval.

Patient Engagement Coordinator

The Providence Community Health Centers, Inc
03.2020 - 01.2023
  • Works with all members of Health Care Team, Accountable Care, and Population Health to achieve coordinated, patient-centered care
  • Demonstrates knowledge of goals and objectives of PCHC’s Accountable Care and Population Health strategies
  • Support Population Health by completing centralized patient assessments and screenings through administrative order entry and other tasks
  • Performs clinical activities under direction of supervising medical professional, including clerical work, medication reconciliation, screening questionnaires, chart preparation, entering data into medical records and executing standing orders, telephone outreach, and visit planning
  • Use tools, such as Population Health application, to create outreach cohorts, address gaps in care, and generate reports
  • Provide general clerical support including, but not limited to, filing, answering/ rerouting calls, and Electronic Health Record functions according to PCHC Policy & Procedures
  • Assist patient needs including, but not limited to, understanding how to access care appropriately, how to access community resources, and how to address barriers to care
  • Schedule patients using automated appointment scheduling process
  • Assists in ensuring that digital faxes, scanning mail and other external communication are correctly handled
  • Manages patient data collection via work queues, databases and electronic health record
  • Work independently to maintain detailed, timely, accurate records and documentation, including accurately and effectively documenting patient interactions in Electronic Health Record
  • Maintains confidentiality at all times: Protecting patient’s rights to confidentiality and privacy, including but not limited to health records, and other medical correspondence reports
  • Support PCHC’s mission, vision and values as it relates to customer satisfaction in all interactions with patients, visitors, providers and staff with understanding and sensitivity to age, spiritual and cultural diversity
  • Demonstrates professional conduct by appropriate communications, respect and courtesy to individuals
  • Represent organization with a positive, professional attitude when communicating with patients and visitors of health centers.
  • Built and maintained relationships with community organizations.
  • Developed and implemented dynamic communication strategies.

Health Home Case Manager

Discovery House
01.2018 - 03.2020
  • Perform patient care, evaluate patient needs, and successfully case manage assigned patients
  • Maintain timely and accurate documentation for our patient records
  • Maintained strict patient data procedures to comply with HIPAA laws and prevent information breaches
  • Communicate regularly with patients, family members, supervisors, physicians, and team members on pertinent patient information
  • Conducted regular evaluations to address changes in needs and conditions, and introduced revisions to care plans
  • Answered patient calls, identified issues and determined how to best provide assistance with parameters established by facility and supervisor
  • Responded to emergency situation with speed, expertise and level- headed approaches to provide optimal outcome, support and life saving interventions
  • Advocated for patient needs wit interdisciplinary team and implemented outlined treatment plans
  • Utilized computerized Resource and Patient Management Systems (RPMS) and Electronic Health
  • Record (EHR) systems
  • Other duties as assigned
  • Educated patients and families on disease processes, medications and treatments.
  • Provided physical assessments, medication, and chronic disease management to home health patients.
  • Worked with multidisciplinary team to carry out successful treatment plans for diverse acute and chronic conditions.
  • Monitored vital signs, developed and implemented care plans, and documented patient progress.
  • Coordinated with other healthcare team members to support patient needs.
  • Provided emotional support and kind companionship to patients and families to increase overall wellness.

Licensed Practicing Nurse- Dosing Nurse

Discovery House
10.2016 - 03.2020
  • Patient dosing according to Discovery House policy, procedure, and protocol
  • Obtain appropriate patient identification prior to dosing
  • Manually dose patients if necessary
  • Accurately update patient medical and/or dosing record per physician orders
  • Manage and reconcile narcotic inventory (Methadone HCL) per Discovery House policy, procedure, and protocol and according to all regulatory standards
  • Maintain, calibrate and manage dispensing equipment (pump, balance, etc) per manufacturer specifications as indicated
  • Obtain reports daily and as determined by established Discovery House protocol and procedure
  • Maintain security of dispensing area according to Discovery House policy, procedure, and protocol
  • Maintain cleanliness of dispensing area
  • Assist physician with physical exams and related direct care activities
  • Perform infectious disease and other medical counseling including review of abnormal lab values for patients and assist with referrals as needed
  • Provide patient education in health related issues
  • Assist in the facilitation of health maintenance groups
  • Document all services, in the patient record, to reflect Health Home Services
  • Obtain and sustain Motivational Interviewing proficiency
  • Coordinate patient care with outside organizations
  • Assist with quality improvement projects and activities
  • Perform other duties as requested

Clerk Specialist

Rhode Island Hospital
10.2016 - 01.2017
  • Under general supervision but according to established policies and procedures performs specialized and complex clerical function
  • Utilizing judgement and a thorough knowledge of Department Hospital and external agency systems and operations regarding a specialized function researches and reconciles clerical procedural and judgement errors
  • Gathered and interpreted information from many sources and prepared summarizes and expedited the processing of such information
  • Reviewed edits and verified the accuracy of a variety of records reports financial statements and other items
  • Identified errors which may be clerical procedural and occasionally judgmental in nature researches all available sources and makes adjustments to reconcile error as necessary
  • Provided resource assistance to other clerical personnel both within and outside the immediate work area and assists in resolving operational and/or technical problems by researching source of problems and making recommendation for resolution utilizing through knowledge of Departmental and/or Hospital accounts
  • Coded indexes logs classifies and files materials requiring thorough knowledge of appropriate coding formats and the Department s record processing and maintenance systems
  • Performed complex accounting and clerical functions such as processing posting and balancing settlements to patient accounts from various third-party payers requiring knowledge of the regulations policies and procedures of the specific third-party payer as well as those of the Department
  • Interacted with patient representatives of the specific third-party payer and other Hospital departments to explain process and expedite settlements
  • Typed reports statistical tables forms and other documents in conjunction with own work
  • Operated an on-line computer terminal similar in operation to a typewriter in order to input report corrections accounting figures
  • Conduct special projects for the Department utilizing experience-based knowledge of Departmental and Hospital policies procedures and operations
  • Operate a variety of standard and/or automated office equipment such as a photo-copier calculator and microfilm viewer
  • Participate in the orientation of new clerical employees to the Department by explaining procedures and providing assistance as necessary

Unit Assistant-ER

Rhode Island Hospital
12.2014 - 09.2016
  • Adhered to company policies and compliance regulations to protect patient confidentiality
  • Upheld knowledge of medical terminology and nomenclature
  • Identified and oriented new staff members before deployment to assigned stations
  • Stocked medical materials and equipment to maintain essential items for unit
  • Collaborated with multi-disciplinary staff to improve overall patient care and response times
  • Oversaw office stock and inventory by checking stock and ordering new equipment and materials
  • Adhered to HIPAA requirements to safeguard patient confidentiality
  • Kept office spaces well stocked with administrative medical

Transporter

Rhode Island Hospital
06.2011 - 12.2014
  • Transported patients by wheelchair or stretcher to areas within the hospital
  • Collected laboratory specimens, x-rays, lab reports and prescriptions and distributed these to the appropriate areas
  • Moved equipment and/or other moderately heavy equipment such as hospital beds, carts cardiac monitors and supplies
  • Collected and returned transport vehicles (wheelchair and stretchers) to appropriate area
  • Prepared vehicles for patients use by cleaning, changing linen and replacing I.V poles.

Education

Diploma - Licensed Practical Nursing

Community College of Rhode Island
Providence, RI
08.2016

Associate - General Studies

Community College of Rhode Island
Providence, RI
05.2014

Skills

  • Medication Administration and scheduling
  • Patient Care
  • Case Management
  • Medical Terminology
  • Management
  • Bilingual- Spanish
  • Typing — Proficient
  • Patient Care & Safety
  • Electronic Medical Records
  • Patient Assessment
  • Vital Signs & Patient Monitoring
  • Privacy / HIPAA Regulation
  • Patient Advocacy and Support
  • Medication Side Effect Knowledge
  • Patient Data Management Systems

Certification

Licensed Practical Nurse August 2016 to March 2024 CPR Certification January 2023 to January 2025 AED Certification January 2023 to January 2025

Timeline

Senior Patient Navigator

The Providence Community Health Centers, Inc
03.2023 - Current

Patient Engagement Coordinator

The Providence Community Health Centers, Inc
03.2020 - 01.2023

Health Home Case Manager

Discovery House
01.2018 - 03.2020

Licensed Practicing Nurse- Dosing Nurse

Discovery House
10.2016 - 03.2020

Clerk Specialist

Rhode Island Hospital
10.2016 - 01.2017

Unit Assistant-ER

Rhode Island Hospital
12.2014 - 09.2016

Transporter

Rhode Island Hospital
06.2011 - 12.2014

Diploma - Licensed Practical Nursing

Community College of Rhode Island

Associate - General Studies

Community College of Rhode Island

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Graciela Morales