Healthcare professional focused on clinical assessment, care coordination, and chronic disease management for medically complex patients. Delivers triage support, medication administration, home visits, and referral coordination while tracking outcomes, abnormal findings, and care plans across primary care, correctional, and military environments.
Overview
1
1
Certification
18
18
years of professional experience
Work History
Nurse Case Manager
Affinia Health Care – PCHH
St. Louis, MO
11.2024 - 09.2026
Managed caseload of 250 Primary Care Health Home patients, conducting monthly clinical assessments and monitoring to track chronic conditions including diabetes, hypertension, and heart disease.
Coordinated care transitions for patients with chronic and behavioral health conditions, conducting post-discharge follow-up calls within 72 hours to enhance patient engagement and reduce readmissions.
Partnered with medical and behavioral health teams to develop care plans addressing chronic disease management and wellness goals.
Educated patients and staff on medical conditions, treatments, and wellness strategies, empowering them with knowledge for better disease prevention and management.
Facilitated health education groups on chronic disease self-management and coordinated referrals to specialty providers, social services, and community resources.
Monitored performance measures and clinical outcomes using health technology systems to support performance improvement initiatives.
Conducted home visits to assess medication adherence, identify safety risks, and reinforce care plans for homebound patients.
Registered Nurse
Corizon Health Care / Correctional Medical Services
Brentwood, TN
08.2008 - 08.2022
Conducted comprehensive physical assessments, health histories, and psychiatric and substance-withdrawal screenings for 874+ inmates in a high-acuity correctional facility.
Triaged urgent and emergent conditions, stabilized patients, and coordinated transfers to hospitals and specialists for higher-level care.
Administered IV therapy, insulin, PPDs, IM injections, and vaccines for high-risk patients on suicide watch in specialized housing units.
Managed care for patients with diabetes, cancer, and mental health conditions in specialized housing units, coordinating treatment plans and monitoring for complications.
Coordinated physician and specialist appointments, diagnostic testing, and post-hospitalization assessments to ensure continuity of treatment.
Performed EKGs, identified abnormal cardiac rhythms requiring provider review, and provided wound care including staple and suture removal for post-surgical and trauma patients.
Monitored patients for adverse reactions to medications and treatments, communicating clinical concerns to medical personnel to facilitate timely interventions.
Collaborated with physicians, hospitals, specialists, and diagnostic service providers to deliver safe, ethical, and patient-centered care.
Responded to medical emergencies throughout the facility, including cardiac arrests and psychiatric crises, stabilizing patients and coordinating transport to higher-level care.
Nurse Case Manager
United States Army
Fort Carson, CO
07.2018 - 06.2021
Conducted comprehensive assessments of Soldiers' functional status and acuity, then developed individualized care plans in partnership with Soldiers, families, and interdisciplinary teams to address complex medical and behavioral health needs.
Managed complex cases involving multiple physical, psychological, and self-care limitations, coordinating services across healthcare disciplines to optimize outcomes.
Managed care transitions between inpatient and outpatient settings and community providers, ensuring seamless continuity of care.
Coordinated discharge planning, referrals, disease management, home healthcare, social services, and community-based support.
Liaised among Soldiers, families, healthcare professionals, and community providers to facilitate effective communication and collaboration.
Coordinated interdisciplinary treatment-team meetings to address changes in patient status and assess education needs, enhancing care plan adherence.
Analyzed medical records to evaluate adherence to clinical pathways and identify care variances, recommending interventions to improve quality and compliance with professional standards.
Identified care barriers and variances from clinical practice, and recommended interventions to improve quality, outcomes, and resource use.
Collaborated with clinical and management teams to develop quality measures, analyze healthcare data, and implement practice improvements using Continuous Quality Improvement methods.
Maintained knowledge of Medicare, Medicaid, and TRICARE requirements, ICD/CPT coding, and clinical-practice guidelines to ensure compliant care coordination.
Education
Master of Science - Nurse Administration
South University
Savannah, GA
01-2024
Bachelor of Science - Nursing
South University
Savannah, GA
01-2014
RN Diploma - Nursing
Lutheran Medical Center School of Nursing
St. Louis, MO
01-2002
Skills
Clinical Skills: Medication Administration, IV Therapy, Wound Care, EKG Interpretation, Phlebotomy, Vital Signs Monitoring, Clinical Assessment, Dressing Change, Drug Administration, Clinical Monitoring
Patient Care: Patient care, Acute Care, General Medicine, Elderly Care, Patient Education, Care coordination: Case Management, Care Planning, Discharge planning, Care transitions, Collaborative care
Care coordination
Infection Control & Safety: Infection Control, Basic Life Support (BLS), ACLS, EBP, Quality Improvement
Specialized Experience: Disease management, Community Health Coordination, Health Insurance Navigation
Staff Nurse band 5 E&D-Adult/Paediatric at Royal Free London NHS Foundation TrustStaff Nurse band 5 E&D-Adult/Paediatric at Royal Free London NHS Foundation Trust