Lissette Figueroa

• Perform professional, consultative, investigative, advisory and education for patients, families and collaborative community agencies
• Assess patients needs and create personal, person centered plans of care that address patients short and long term goals
• Main point of contact between patients and providers to ensure collaboration and coordination of medical, mental health, housing, financial social support and immediate needs
• Connect and assist patients to apply for financial programs such as Social Security, Department of Health and Human Services, Housing subsidies that include Section 8 and The Housing Authority
• Instruct and educate patients on procedures, health care provider instructions, and referrals as well as coordinate transportation services
• Conduct monthly follow up with patients and providers to evaluate progress, promote continuity of care, update care plans, annual comprehensive assessments, CES tool, crisis plans and monthly HML's for billing purposes
• Maintain 99% billiging average on a monthly basis
• Assist patients admitted to Medical and Mental Health Facilities with discharge plans
• Work with patients to follow provider recommendations in an attempt to avoid future admissions
• Address gaps in care to promote health and avoid hospital admissions
• Continue education and training provided by HHUNY, GRHHN and the NY State of Health
• Work with new employees by shadowing, educating on process and procedures, time management and general support
• Reduced hospital readmissions by closely monitoring patients'' conditions and intervening appropriately at early warning signs of complications.
• Developed strong relationships with patients, building trust and providing emotional support during difficult times.
• Demonstrated flexibility in adapting to changing circumstances while maintaining a consistently high level of professional performance under pressure situations.
• Championed patient-centered care philosophies by promoting shared decision-making processes that took into account the unique preferences/values of each individual client being served within our program offerings.
• Provided comprehensive education to patients and caregivers on disease management, medication adherence, and wellness strategies.
• Assisted patients in navigating complex healthcare systems, advocating for their best interests when necessary.

Provides support and direction to assigned team members with the goal of improving overall team performance

• Coach team members on best practices and escalates client/staff concerns to the leadership team
• Exemplifies best practices while performing care management responsibilities
• Provides rehabilitation and supportive counseling geared towards restorations of clients to their optimum level of social and health functioning by assisting clients with the adjustment to their illness and follow medical/behavioral health recommendations
• Development of long and short term plans of care, utilizing community, medical and behavioral health supports
• Completion of assessments/re assessments, crisis plans and ensuring documents are uploaded to client's charts
• Preparation of concise, accurate and timely notes which are incorporated in the client's Netsmart record
• Performs a minimum of 30 monthly face to face contact with clients and collaborators and document client goals. Actively/progressively provide care management services showing multiple points of engagement with a client over the course of a month

• Coordination and Completion of Intakes in the Health Home Program
• Provide Health Home care management services to ensure all those involved in client's care are working together and sharing necessary information in supporting clients recovery
• Coordination or Housing, Medical, Mental Health, Substance Abuse and Services are in place to assist client on their journey to recovery
• Identification of client's goals to ensure everyone involved in clients care understand the goals of our clients
• Served under The Housing Opportunities of People Living with Aids in the HOPWA grant by assisting clients to have safe affordable housing by conducting home inspections, updating income verifications, and advocating with landlords so clients can stay focused on their health
• Training facilitator Housing Laws, Advocacy and the stigma of HIV
• Championed patient-centered care philosophies by promoting shared decision-making processes that took into account the unique preferences/values of each individual client being served within our program offerings.
• Evaluated patient progress regularly, adjusting care plans as needed based on individual needs and preferences.
• Optimized patient outcomes with evidence-based interventions tailored specifically toward individual needs/preferences – such as medication regimen adjustments or lifestyle modifications recommendations that ultimately led towards improved quality-of-life
• Developed strong relationships with patients, building trust and providing emotional support during difficult times.