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
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
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
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
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