KIMBERLY GOMEZ

Scope of Responsibility

• Manage care coordination for 80–100 high-risk Medicaid members with complex chronic conditions.
• Collaborate with 10+ physicians, behavioral health providers, and community organizations to coordinate integrated care.
• Facilitate Interdisciplinary Care Team meetings to align care plans and improve patient outcomes.

Key Responsibilities

• Conduct comprehensive Health Risk Assessments (HRA) to identify high-risk members eligible for care management programs.
• Develop and implement individualized care plans in collaboration with physicians, caregivers, and interdisciplinary healthcare teams.
• Coordinate behavioral health services, community resources, and long-term services and supports (LTSS) to ensure continuity of care.
• Identify and address social determinants of health, including transportation barriers, food insecurity, housing instability, and financial challenges.
• Perform telephonic and in-person outreach to monitor member progress and promote engagement in care management programs.
• Maintain detailed clinical documentation while ensuring compliance with CMS guidelines and regulatory standards.

• Performed in-depth assessments and reassessments of patients, focusing on accurately identifying clinical conditions and necessary care interventions.
• Coordinated efforts among physicians and interdisciplinary teams to ensure effective and comprehensive patient care.
• Established IV access and administered medications through various routes, ensuring compliance with medical protocols.
• Developed and implemented educational sessions for patients and families to enhance understanding of disease management and treatment options.
• Monitored and verified clinical documentation processes to guarantee alignment with regulatory requirements.

• Interface with a multi-disciplinary team including physicians and nursing directors to enhance and maintain client centered care.
• Assist in problem solving with providers and clients using prioritization and requiring minimal direction.
• Maintain knowledge of Medicare, Medicaid and CMS guidelines, and comply with all laws, regulations, policies, procedures and standards.
• Perform OASIS assessment Facilitate admissions, discharges and transfers; and delegate appropriate work assignments on patients and complete accurate and efficient documentation.
• Monitor signs and document patient's progress according to care plan on each visit in conjunction with MD orders.
• Assist patients in understanding pharmacological and non-pharmacological management and treatment of various disorders and diseases.
• Travel throughout 30-mile territory to provide case management assessments to pediatric and geriatric patients diagnosed with chronic/terminal conditions, convalescing from surgical procedures or recovering from serious illnesses and injury.

• Administered patient care following established protocols and best practices.
• Collaborated with interdisciplinary teams to enhance patient outcomes and streamline care delivery.
• Educated patients and families on health management, medications, and post-discharge instructions.
• Monitored vital signs and documented changes in patient conditions for timely interventions.