Compassionate Advanced Registered Nurse Practitioner with comprehensive experience providing acute care, wellness exams, and chronic disease management for diverse and challenging populations. Skilled at analyzing patient histories and preliminary test results to build diagnosis. Organized, dependable, and successful at managing multiple priorities with a positive attitude. Willingness to take on added responsibilities to meet team goals.
• RN Care Manager, Telephonic Nurse 2, employed various strategies, approaches, and techniques to manage a member's physical, environmental, and psycho-social health issues. Identified and resolved barriers that hindered effective care. Ensured patient's progression toward desired outcomes by continuously monitoring patient care through assessments and/or evaluations.
Managed patients with chronic, acute, and complex needs. Facilitating communication, coordinating services, addressing barriers, and promoting optimal allocation of resources while balancing clinical quality and cost management.
• Focused on identifying high-cost, complex at-risk individuals with acute and chronic needs, management of acute events, and proactive management of anticipated health care needs.
• Focused on readmission prevention for patients moving from one care setting to another.
• Contacted patients post discharge from acute care or emergency room within 48 hours.
• Focused on patient understanding of discharge instructions, medications and follow-up appointments.
Disease management and prevention:
• Identified patients with chronic conditions such as Asthma, Hypertension, Diabetes, CAD, CHF, COPD and CKD and develop plans of care for those high-risk patients (ex. Diabetes management classes).
• Provided resources for patient related to DME, medication, primary care physicians, urgent care centers, home health, etc.
Decrease emergency room utilization:
• Assisted patients with finding a PCP to oversee their care.
• Provided list of urgent care clinics in the community to the patient.
• Provided weekly case management follow-up calls for 30 days post-acute hospitalization as a resource.