Capable Medical Social Worker well-versed in educating patients, coordinating treatment plans and setting up program referrals. Knowledgeable about documentation, recordkeeping and insurance requirements. Using 20 years of experience in field to deliver exemplary patient support.
Overview
17
17
years of professional experience
Work History
Transition of Care Team, Care Coordinator
Northside Forsyth Hospital
Cumming, GA
01.2015 - Current
Readmission team consisting of Nurse Practitioner, Pharmacist, Nurse, and myself.
Team follows Medicare Patient's with diagnosis of COPD or Pneumonia.
Rounded on patients while in hospital, establishing mutual goals with patient and all Clinicians, and continue to monitor patients post-discharge for 30 days.
Performed psychosocial assessment, asses for post-acute care needs, and evaluate potential gaps in plan in collaboration with TOC Team.
Team lead yearly Symposiums for Healthcare Professionals, conducted yearly community out-reach programs for Forsyth/Cherokee counties, Coordinated with local middle schools to provide educational seminars on Vaping
Care Coordinator
Northside Forsyth Hospital
Cumming, Georgia
01.2014 - 01.2015
Completed Utilization Reviews within MCCM/Cerner platforms using Interqual for reviews.
Coordinated with Physicians, Nurses, Therapist, Behavioral Health, and Patient Relations to establish plan of care and goals for discharge needs.
Completed assessments on patients throughout their stay to establish safe discharge plan.
Completed referrals to Home Health Care companies, Assisted Livings, Skilled Nursing Homes for rehabilitation and/or long term care, Long Term Acute Care, Acute Care Rehabilitation, and needs based community care services.
Assisted patients in finding solutions to appropriate housing, transportation options, food banks, domestic violence shelters, and homeless shelters.
Admissions Coordinator Liaison
Brian Center Health And Rehabilitation Of Canton
Canton, GA
08.2013 - 12.2013
Coordinated with Case Managers at Northside Cherokee Hospital, Wellstar Hospital Marietta, and Northside Forsyth Hospital on referrals to facility to ensure smooth transition at discharge.
Met with patients and families at hospital to explain admission criteria and patient appropriateness for Skilled Nursing Rehabilitation.
Confirmed all insurance benefits met standards of admissions as dictated by policy.
Assisted in patient admission process based on federal and state laws.
Social Worker Discharge Planner
North Fulton Hospital
Roswell, GA
09.2012 - 08.2013
Solved problems related to abrupt changes in discharge, coordinated updates and communicated discharge plans.
Worked with utilization review to establish prior authorization for timely discharges.
Communicated with referral providers about new referrals and verified receipt of necessary information prior to arrivals.
Facilitated timely referrals to alternate levels of care and assisted family or guardian with completion of applications.
Medical Social Worker
Interim Health Care
Pickens, SC
06.2005 - 06.2012
Provided Home Health case management for children, adolescent, adult and geriatric patients
Worked with Interdiscipline Team consisting of MD, RN, PT, OT and Home Health Aide
Completed Home Visits/ phone assessments, psychosocial evaluations/ needs assessments, MMSE, depression screenings, Advanced Directive teaching, long term care planning, and SNF/ALF/ in-patient rehab placements, coordinating community resources, and educating population on how their environment/ choices affect their disease process.
Education
Master of Science - Social Work
Jackson State University
Jackson, MS
05.2003
Bachelor of Science - Social Work
University of Southern Mississippi
Hattiesburg
05.2000
Associate of Arts - Social Work
Hinds Community College
Raymond, MS
05.1997
Skills
Utilization Reviews
Educating Families
Quality of Life Guidelines
End of Life Goals of Care
Psychosocial Assessments
Coordination with Post Acute Care Providers
Coordination between all disciplines
Arrangements of all services needed post discharge