Kathleen Silva
Saint Cloud
Summary
Accomplished R.N. Case Manager with a proven track record at HCA Florida Hospital Osceola, adept in chronic disease management and fostering resilience among patients. Excelled in reducing readmission rates and enhancing patient outcomes through a multidisciplinary approach and effective discharge planning. Skilled in HIPAA compliance and quality improvement, demonstrating a commitment to excellence and patient advocacy. Excellent Community Based relationships within Osceola County.
Overview
9
9
years of professional experience
Work History
R.N. Case Manager
HCA Florida Hospital Osceola
10.2022 - Current
- Provided emotional support to patients coping with acute or chronic illness or end-of-life decisions, fostering resilience during difficult times.
- Managed complex cases involving multiple comorbidities, requiring close monitoring and coordination of various healthcare services.
- Reduced hospital readmission rates through effective case management and patient education on self-care techniques.
- Advocated for patients with insurance companies, securing coverage for necessary treatments and medications.
- Collaborated closely with physicians to develop individualized treatment plans, supporting optimal patient outcomes.
- Educated patients and families on available community resources, facilitating access to necessary support services.
Lead MDS Coordinator
Avante St Cloud
Kansas Ave St Cloud Florida
03.2018 - 09.2022
- Set schedules for staff to start and complete MDS assessments and care plan meetings.
- Ensured timely completion of all MDS assessments, maintaining full compliance with federal and state regulations.
- Maintained up-to-date knowledge on CMS guidelines and changes to ensure accuracy in reporting and reimbursement processes.
- Assessed electronic medical record for required documentation to support MDS coding.
- Collaborated closely with therapy departments to accurately capture rehabilitation needs within MDS documentation, supporting appropriate resource allocation for residents'' needs.
- Provided ongoing education for nursing staff regarding MDS best practices, contributing to a knowledgeable and skilled workforce.
- Monitored changing regulations related to RAI/MDS requirements, keeping staff informed about updates that impact their daily work routines.
- Conducted audits of current MDS records to identify discrepancies and improve record accuracy, enhancing reimbursement rates for the facility.
Supervisor Home Health RN
Nurse On Call Home Health
Lake Nona FL
02.2017 - 03.2018
- Oversaw daily operations of the department, ensuring smooth workflow and timely completion of new patient assessments.
- Applied strong leadership talents and problem-solving skills to maintain team efficiency and organize workflows,By coordinating with Physical and occupational therapy staff.
- Improved customer satisfaction with timely response to inquiries, addressing concerns, and finding effective solutions.
- Increased team productivity by implementing efficient workflows and setting clear expectations for staff members.
- Rn Comprehensive patient assessments to determine nursing needs,data collection using EMR for Oasis.
MDS Coordinator
Plantation Bay
Canoe Creek St Cloud Florida
09.2015 - 01.2017
- Utilized critical thinking skills to prioritize nursing interventions based on patients'' acuity levels and individual needs.
- Conducted thorough patient assessments to identify changes in condition, promptly notifying physicians and initiating appropriate interventions when necessary while capturing correct coding for MDS.
- Assisted in the training and mentorship of new nursing staff members, contributing to a positive work environment and high-quality patient care.
- Contributed to interdisciplinary team meetings by presenting relevant clinical data about patients'' progress toward reaching established goals of care.
- Facilitated patient transitions between different levels of care, ensuring continuity of services and minimizing disruptions in treatment plans.
- Observed and documented patient factors such as diets, physical activity levels, and behaviors to understand conditions and effectively Implement and or modify care plans.
- Act as a guide liaison for state survey teams.
- Set schedules for staff to start and complete MDS assessments and care plan meetings.
- Ensured timely completion of all MDS assessments, maintaining full compliance with federal and state regulations.
Education
Associate of Science - Nursing
Pasco Hernando State College
11415 Ponce DeLeon Blvd BrooksvilleNursing
Galen College of Nursing
ST Petersburg FlSkills
- Chronic disease management
- Discharge planning
- HIPAA compliance
- Multidisciplinary approach
- Quality improvement
- Utilization review
- Community resources
Timeline
R.N. Case Manager
HCA Florida Hospital Osceola
10.2022 - Current
Lead MDS Coordinator
Avante St Cloud
03.2018 - 09.2022
Supervisor Home Health RN
Nurse On Call Home Health
02.2017 - 03.2018
MDS Coordinator
Plantation Bay
09.2015 - 01.2017
Associate of Science - Nursing
Pasco Hernando State College
Nursing
Galen College of Nursing