Margaret Perez BSN, RN, CCM

Coordination of care for approximately 90-100 clients. Complete face to face and telehealth visits, coordinate care for clients with other agencies, durable medical equipment, provider agencies, skilled nursing services and physicians. Approve authorizations for services, develop and implement care plans to address clients needs and goals. Ensuring members needs are met within the scope of the waiver program.

Manage a caseload of 100-125 clients. Face to face and telehealth assessments, assist with ensuring clients met medical necessity, authorized services as needed that include provider services, skilled nursing services, home modifications and durable medical equipment. Collaborated with physicians offices and other disciplines as the situation warranted.

Completed reassessments for the Community Based Assistance program to determine medical necessity. Evaluation of client’s homes for home modification. Teaching and training of attendants and supervised accordingly. Coordination of care which included referring to home health agencies, collaborating with physicians, social workers and other disciplines.

Responsible for overall function of agency, which included assessments, patient care, and coordination of care. Monitored and evaluated nursing staff and provided feedback and guidance to support standards of care for both Community Based and Primary Home Care. Reviewed and enforced policy and procedures for the agency.

Field nurse performed home health assessments, skilled nursing interventions. Case Manager role included coordination of care, collaborating with physicians and other clinical disciplines and discharge planning. Director of Nursing was responsible for overall function of agency, implementing agency policy and procedures. Worked with multidisciplinary team to care out successful treatment plans for home health clients. Responsible for educating, training and supervising nursing staff.

In Home assessments, providing skilled nursing care that include all aspects of care such as vital signs, wound care, education, IV therapy. Conducted initial assessments as well as post hospital assessment and continuation of services. Coordinated care for each member and reported abnormalities to their physicians.

Performed varies nursing duties and nursing interventions on the medical and surgical floor.