Kelly Smith
Rainsville,AL
Summary
Registered Nurse with almost 20 years' experience in providing quality patient care in a wide variety of healthcare settings. A critical thinker, excellent communicator, self-driven, motivated, reliable, and trustworthy, professional employee.
Overview
19
19
years of professional experience
1
1
Certification
Work History
ACHN Care Coordinator
My Care Alabama East
Gadsden, AL
03.2020 - Current
- Blue Cross Blue Shield of Alabama subsidiary company responsible for coordinating care for eligible individuals (EIs) assigned by the State of Alabama Medicaid Office. Developing care plans and following up in a timely manner to improve the EIs overall health. Frequently involving face-to-face meetings with the EIs to gain a full understanding of their challenges. Providing services to home care and community-based populations identified as needing care management and transitional services from inpatient facilities. Monitoring QIP standards and assisting EIs to meet goals/measures and reduce gaps in care. Assist with obtaining Specialist referrals, scheduling appointments and needed community resources, while meeting agency standards and maintaining PIP goals.
ACO POPULATION HEALTH NURSE.
QUORUM HEALTH
Fort Payne, AL
06.2018 - 03.2020
- Care Coordination, Chronic Care and Transitional Care manager for DeKalb Regional Hospital and Provider clinics. Communicator and Quality Improvement management for Hospital and Provider Clinics at ACO level. Obtaining data and improving Quality Measures, completing Medicare AWVs. ACP, PHQ9s and Fall Risk Screenings. Transition of Care Management for patients discharged from inpatient settings returning to home. Chronic Care Management for chronically ill patients. Facilitate Quality Improvement activities that educate, support, and monitor for providers of the ACO. Monitor preventative screenings for patients. Auditing EHR for accuracy, gathering, completing, and submitting Quality Measures for Medicare Reporting and MSSP. Work as a data manager to measure processes of care and outcomes, analyze data and seek innovative solutions to improve quality of care.
CLINICAL MENTOR
ALACARE HOME HEALTH AND HOSPICE
Rainsville, AL
11.2014 - 06.2018
- Managed all new employee orientation. Functioned as a teacher, mentor, and supervisor to new orientees and graduate nurses. Coordinated with the Education department to develop an individualized orientation plan, evaluate new employee progress and address training issues. Ensure comprehensive and accurate hands-on patient care/skills and documentation. Trained new employees to use Homecare Homebase EMR for health care documentation. Created Employee Performance Reviews as needed and medical chart/documentation auditing.
Home Health/Hospice RN Case Manager
ALACARE HOME HEALTH AND HOSPICE
Rainsville, AL
11.2004 - 11.2014
- Served as a patient advocate, provided hands on skilled nursing care and skills in patient’s home. Completed Patient assessments including physical, emotional, psychosocial, and environmental. Medication management. Identify patient needs and make appropriate referrals. Collaborate with other Nurses, Therapist, Care Managers and Physicians. Supervised LPNs and HCAs. Provided comprehensive education for patients and their families. Provided documentation to EMR via HomeCare HomeBase.
Education
Bachelor of Science - Nursing
WESTERN GOVERNORS’ UNIVERSITY
Salt Lake, NM09-2021
Associate of Science - Nursing
Northeast Alabama Community College
Rainsville, AL05-2004
Associate of Applied Science - Paralegal
NORTHEAST ALABAMA COMMUNITY COLLEGE
Rainsville, AL05-2002
High School Diploma -
Section High School
Section, AL05-1999
Skills
- Multidisciplinary Team Collaboration
- Progress Monitoring
- Case Management
- Goal Setting
- Interdepartmental Collaboration
- Insurance Practices
- Organizational Skills
- Patient Education
- Program Oversight
- Process Improvements
- Care Planning
- Quality Assurance
- Documentation
- Healthcare Operations
Accomplishments
Assisted with developing ACO (Accountable Care Organization) Population Health, Transitional Care Management and Chronic Care management programs and roles at DeKalb Regional Medical Center.
Have met and exceeded goals and expectations for Quality Measures monthly.
Light Beam super user.
CMS reporting for 2018/MIPS.
Appointed as a SME (Subject Matter Expert) for HCAT and CGX 2.0 rollout of new electronic documentation programs.
Created disease specific education maps for new and established nursing staff.
Direct oversight of new employee training, education and orientation. Completed chart audits for new employees.
Assisted with yearly employee evaluations.
Certification
- Obtained WTA (Wound Treatment Associate) from WOCN (Wound and Ostomy Care Nurse) for additional education and skills providing wound care.
- American Heart Association BLS instructor.
- NCCDP (National Council of Certified Dementia Practitioners) certified in Dementia care.
- ELNEC (End-of-Life Nursing Education Consortium) certification for advanced end of life care.
References
References available upon request.
Timeline
ACHN Care Coordinator
My Care Alabama East
03.2020 - Current
ACO POPULATION HEALTH NURSE.
QUORUM HEALTH
06.2018 - 03.2020
CLINICAL MENTOR
ALACARE HOME HEALTH AND HOSPICE
11.2014 - 06.2018
Home Health/Hospice RN Case Manager
ALACARE HOME HEALTH AND HOSPICE
11.2004 - 11.2014
Bachelor of Science - Nursing
WESTERN GOVERNORS’ UNIVERSITY
Associate of Science - Nursing
Northeast Alabama Community College
Associate of Applied Science - Paralegal
NORTHEAST ALABAMA COMMUNITY COLLEGE
High School Diploma -
Section High School