LIEZL JOY FLORES

Facilitated timely discharge planning and follow-up to reduce readmissions.
- Acted as a liaison between providers, patients, and families to ensure smooth care transitions.
-Documented and escalated utilization concerns, delay in care, and resource needs to the appropriate care management or administrative teams.
- Provided education to patient and families regarding post- discharge care, follow-up appointments, and available community resources.
- Serve as a clinical point of contact to staff nurses, providers, patients, and families to ensure continuity of care.

- Supervised and managed daily scheduling, tasking, and administration.

- Facilitated therapeutic communication, conflict resolution and crisis intervention by redirecting negative behaviors and helping patients regain or improve coping abilities.

- Delivered high level of quality care to diverse populations while overseeing patient admission and triaging based on acuity and appropriate department admission.

- Collaborated with interdisciplinary teams to assess patient needs, plan care, and support timely discharges.
- Identified patients requiring case management referral based on clinical and psychosocial indicators.
- Monitored patient progress and resource utilization to support efficient, cost- effective care.
- Provided patient and family education to enhance self- care and reduce risk of readmission.
- Communicated with providers and care coordinators to align treatment plans with utilization goals.

- Performed various nursing interventions such as wound dressing, vital sign monitoring, and specimen collection.

- Precepted student nurses and oriented new hires, providing guidance and mentorship when teaching on hospital policies, emergency procedures, and nursing best practices.

- Directed patient care by initiating and following through with plan of care, continuing care, and discharge instructions.

- Educated patients, families and caregivers on diagnosis and prognosis, treatment options, disease process, and management and lifestyle options.

- Participated in hospital committees to recommend quality improvement initiatives.

- Followed all personal and health data procedures to effectively comply with HIPAA laws and prevent information breaches.

- Managed care for medically complex patients requiring extended hospitalization and high-resource utilization.
- Collaborated with interdisciplinary teams on care planning, discharge readiness, and care transitions.
- Monitored patient progress and communicated changes to support timely interventions and efficient resource use.
- Identified patients case management referral and contributed to coordination of post- acute care needs.
- Educated patients and families on long-term care goals, discharge plans, and follow-up resources.

• Provided physical assessments, medication, and chronic disease management to home health patients.
• Traveled to patients' homes on daily basis to assess health conditions and provide superior level of nursing care.
• Worked with multidisciplinary team to carry out successful treatment plans for diverse acute and chronic conditions.
• Informed physicians of any changes to patients' health or concerns observed during home visits.
• Conducted in-home assessments to develop individualized care plans aligned with patient goals and payer requirements.
• Evaluated medical necessity, skilled need, and visit frequency to ensure appropriate utilization of home health services.
• Coordinated care with physicians, therapists, and care givers to promote safe, goal-directed outcomes.
• Identified barriers to recovery and connected patients with community resources or escalated to case management.
• Educated patients and families on chronic disease management, medication adherence, and discharge readiness.
• Documented patient progress and communicated status updates for ongoing utilization and authorization processes.