Lisa Smith

NURSE CARE MANAGER
Included Health - San Francisco, CA /Dec 2021-Present

• Work in a virtual environment to provide coordinated, holistic, patient-centered care
• Assess member needs upon discharge from the hospital; coordinate care with hospital based case manager and provide support to members post discharge
• Collaborate with members of the multidisciplinary team at Included Health including clinicians, dietitians, social workers, pharmacists and psychologists to provide necessary support to members
• Determine member's short and long term health related goals and develop an individualized plan of care to help member achieve desired outcomes
• Provide education, resources and support to members to help them independently manage their health conditions and self advocate for an appropriate treatment plan
• Collaborate with local providers and hospital based case managers and other representatives of the health care team to optimize outcomes
• Build trusting relationships with members and consistently have among the highest enrollment and reach rates compared to my peers
• Created and executed a successful end to end pilot focused on increasing member enrollment which exceeded the high end of goal by 53%.
• Member of a select group of colleagues chosen for expertise in Acute Case Management (ACM) to develop a focused assessment tool to improve work efficiency and positive member outcomes
• Identify risk with new workflow enhancements and collaborate with leadership on improvements to help with implementation
• Collaborated with colleagues from various disciplines throughout Included Health including Sr. Strategy and Operations Manager, Sr. Product Designer, Director of Strategy and Operations for Clinical Services in an effort to improve efficiency and workflow within the CCM program
• Precept and mentor new nurse care managers
• Provide support and answer general questions for teammates as required

• Provide coordinated holistic, patient-centered care telephonically to members from diverse populations within a population health management program
• Identify members at high risk through risk stratification tool
• Determine member's health related goals and develop an individualized plan of care to help member achieve desired outcomes
• Educate and support members to help them become more independent with managing their health conditions
• Collaborate with physicians, utilization review nurses, hospital case managers and other representatives of the health care team to optimize outcomes
• Coordinate resources required to meet the needs of the member
• Monitor, record, and report symptoms or changes in patients' conditions
• Maintain accurate, detailed reports and records
• Consult and coordinate with healthcare team members to assess, plan, implement, or evaluate patient care plans
• Provide education to patients and families to improve health outcomes
• Served on unit in a managerial role as a Clinical Care Leader as well as Charge Nurse and Preceptor