Kathleen Bannach

Assess, plans, implements, coordinates, monitors & evaluates all options & services with the goal of optimizing the patient's health status. Manages utilization & practice metrics to further refine the deliver of the care model to maximize clinical, quality, and fiscal outcomes

• Managed caseload of 130-140 including patients with chronic illness, frequent utilization. psychosocial issues
• Conducting patient assessments, developing & implementing care plans. including patient, family & primary care provider, other members of the health care team. adjusting care plans as needed
• Evaluates laboratory results, diagnostic tests and metrics to monitor quality & efficiency
• Works to apply benefits & utilization management serving as a resource to the member & health care team
• Works with members to prevent readmissions by providing close follow up after hospitalizations thru telephonic & in person. utilizing systems of care that monitor patient progress such as AMC & Current Health Platforms
• Monitors members in long term acute care, acute rehabilitation and skilled nursing facilities to prepare for discharge follow up
• Participated in advanced care planning with patient's & families

• Advocated for patients by communicating care preferences to practitioners, verifying interventions met treatment goals and identifying insurance coverage limitations.
• Effectively communicated with physicians regarding patient needs, performance, medications and changes.
• Participated in patient and family planning process, as well as provided instructions and addressed question and concerns.
• Completed initial assessments of patients and family to determine and address individual home care needs. ·
• Examined patients and documented history of current and previous conditions, illnesses, injuries and current medications.

• develop census as defined by targeted goals of business plans
• developed referral relationships within an assigned geographic territory
• assisted with coordination of the referral-to-admission process by completing referral assessments, communicating with rehabilitation provider
• provided in-services and professional presentations for referral sources, community groups educating them on rehabilitation services, programs and outcomes