Joydell Cebula
Westerly,RI
Summary
Registered Nurse/Healthcare professional with experience at Commonwealth Care Alliance, excelling in patient/member care coordination and discharge planning, patient advocacy, and care transition processes. Proven ability to enhance patient outcomes through effective communication and problem-solving. Strong focus on team collaboration and achieving results. Reliable, adaptable, and skilled in communication, and multi-tasking in fast-paced environments.
Overview
11
11
years of professional experience
Work History
Transitions of Care Discharge Coordinator
Commonwealth Care Alliance
05.2020 - Current
- Promotes a collaborative environment among colleagues by sharing best practices for efficient coordination across departments involved in the discharge process.
- Collaborates daily with hospital case managers and social workers to arrange for placement of members in facilities appropriate for level of care requirements, or home with services when appropriate.
- Provides admit notification and comprehensive discharge instructions and resources to community care partner for follow-up care with members once in community.
- Works collaboratively with clinical and non-clinical team members to solve complex discharge issues.
- Case Conferences with team members to reduce readmission rates through thorough review of patient records and implementation of individualized care plans, services prior to member's discharge.
- Manages caseloads effectively, prioritizing high-risk cases for more intensive support during the transition period following discharge from the hospital setting.
- Evaluated patients'' needs upon admission, working closely with the medical team to develop appropriate discharge plans accordingly.
- Increases efficiency in the discharge process, implementing electronic record-keeping systems to track essential information.
- Maintains up-to-date knowledge of regulatory requirements, ensuring compliance with all applicable laws and guidelines related to patient discharge processes.
- Improves patient discharge process by coordinating with medical teams and ensuring timely communication between departments.
- Authorized medically appropriate facility admissions and transportation.
- Attends weekly team huddles with manager and/or director to discuss work flows, changes, challenges, and difficult inpatient cases.
- Attends weekly meetings among TOC DC Coordinators/care partners, Team TOC manager with hospital case management leadership to discuss long LOS members, complexities and discharge barriers of inpatient members.
- Kept high average of performance evaluations.
- Resolves issues through active listening and open-ended questioning, escalating major problems to manager.
- Provided training for new staff members, fostering a culture of continuous learning within the department.
- Utilizes a checklist to ensure that the components of a safe transition of care occur
- Collaborates with facilities, IDT members and others involved in participants plan of care to ensure safe, efficient transitions from facility to facility and to the home setting
- Communicates daily with primary team members to address potential barriers to discharge or transition to lesser care setting
- Acts as a liaison between facilities and IDT members to convey progress, charting progress notes in member's medical record.
- Recognizes, identifies, and implements appropriate opportunities to help meet Utilization goals
- Enters authorizations in applicable systems to ensure that claims are adjudicated efficiently
- Utilize clinical judgement and critical thinking to suggest alternative measures for provision of care
- Documents all inpatient care transitions and case management progress notes within the electronic health record
- Generate Transitions of Care Templates to accurately reflect transitions and level of care
- Determined tier of service at subacute facilities
- Participates in contracted facility case management meetings to address potential barriers/facilitate successful discharge planning.
- Worked with utilization review to establish prior authorization for timely discharges.
- Communicates with referral providers about new referrals and verifies receipt of necessary information prior to discharge.
- Facilitate pertinent record exchange to and from facilities for continuity of care and medication reconciliation
Registered Nurse Intake Manager
Porchlight VNA/Home Care
08.2019 - 05.2020
- Screened, triaged, and assessed the appropriateness of referral requests for agency services inclusive of admission criteria and discipline utilizing a solid understanding of home care and payment sources, in addition to the 2020 Medicare/PDGM guidelines
- Obtained pertinent diagnosis, specifically those accepted by Medicare under PDGM guidelines, MD orders to assess, teach, provide direct care. Ensured all data was accurate and complete
- Worked collaboratively with billing, scheduling, and management to ensure and facilitate the home care services were in compliance with all regulatory and agency guidelines. Obtained delay in initiating services from Certifying MD as necessary
- Demonstrated knowledge of home care processes in all communications with referral sources, communicating in a timely manner with all sources via phone, fax and electronic referral sources; Allscripts, 4Next, and Navi-Health.
- Communicated effectively with external and internal staff, and referral sources.
- Entered, processed referrals, in addition to entering medications prior to initiation of care, through a task driven system, Home Care Home Base
- Entered MD orders; labs, wound care, medication changes, into patient chart in HCHB
- Approved written orders from field staff through the work flow task-driven system HCHB
Registered Nurse Intake Coordinator
Holyoke VNA & Hospice Life Care
11.2015 - 08.2019
- Screened, triaged, and processed requests for agency services inclusive of admission criteria and discipline utilizing a solid understanding of home care and payment sources.
- Accessed the appropriateness of each referral according to agency policies and procedures and in collaboration with the primary physician and referral sources.
- Ensured all pertinent data was accurate and complete. Utilized all available information and sources to promote quality care.
- Identifid and communicated priority visit needs and potential high-risk situations to the clinical manager to facilitate timely and appropriate scheduling.
- Worked collaboratively with scheduling, billing and management to ensure and facilitate the home care services were in compliance with all regulatory and agency guidelines.
- Communicated effectively with all internal and external contacts utilizing excellent customer service skills.
Registered Nurse Case Manager, Hospice
Life Choice Hospice
09.2014 - 04.2015
- Served as a liaison between patients, families, and healthcare providers to ensure seamless communication and continuity of care.
- Evaluated the effectiveness of current hospice services through regular audits and feedback from patients, families, and staff.
- Participated in continuous professional development to stay current with best practices in hospice case management and end-of-life care.
- Educated families on the hospice process, enabling informed decision-making during a difficult time.
- Enhanced patient care by developing personalized hospice plans and coordinating interdisciplinary team efforts.
- Provided direct nursing care when necessary, ensuring the highest level of comfort for patients facing terminal illness.
- Improved family satisfaction by providing compassionate support and regular communication on patient progress.
- Supported bereaved families through grief counseling resources and post-mortem follow-up calls, demonstrating genuine compassion during times of loss.
- Collaborated with physicians to develop comprehensive pain management strategies for patients in their final days.
- Recognized and understood specific stages of dying process, providing comfort-based care during vulnerable times.
- Worked closely with hospice Social Worker, Chaplin, Home Health Aids, and volunteers to coordinate physical, emotional, and spiritual care of the patient and family.
Education
Associate of Science - Nursing
Capital Community College
Hartford, CT05-2010
High School Diploma -
Bloomfield High School
Bloomfield, CT06-1985
Skills
- Care coordination
- Discharge planning
- Teamwork and collaboration
- Problem-solving
- Time management
- Attention to detail
- Reliability
- Adaptability and flexibility
- Works well independently
- Task prioritization
- Effective communication
- HIPAA compliance
Timeline
Transitions of Care Discharge Coordinator
Commonwealth Care Alliance
05.2020 - Current
Registered Nurse Intake Manager
Porchlight VNA/Home Care
08.2019 - 05.2020
Registered Nurse Intake Coordinator
Holyoke VNA & Hospice Life Care
11.2015 - 08.2019
Registered Nurse Case Manager, Hospice
Life Choice Hospice
09.2014 - 04.2015
Associate of Science - Nursing
Capital Community College
High School Diploma -
Bloomfield High School
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