Mary Roman-Roche LPN

• Case manager 600 to 800 managed care patients.
• Hospital and SNF transitions of care
• Report to primary care provider and or specialist of changes and or care needed.
• Assess patient's for home health services.
• Patient and caregiver education.
• Monitoring hospitalized patients and anticipate services and or referrals needed to prevent readmission.
• Maintain open lines of communication with patients, families and primary care providers at Optum.
• Cover administrator in office when they are off or on vacation.
• Weekly hospital and SNF rounds with Medical Director. Report on patient's condition and discuss care plan with team and medical director.
• Present procedures and or referrals with medical director.
• Use CMS and Millman Criteria in order to provide proper care patient require.
• Attend monthly meetings with leadership in order to review monthly updates on risk patient.
• Process referrals for patients and work with care coordinators and insurance plans.
• Work with patient and family to provide quality care and services within Medicare guidelines.
• Submit reports to corporate for delegated insurances.
• Precept fellow care management teammates.
• Reporting and utilizing Excel, Sharepoint, Focus and other computer applications.

• Process referrals for potential patents
• Reviewed incoming referrals for required components needed such as signed referrals, clinicals and demographics.
• Monitoring patients when hospitalized or admitted into a skilled nursing facility. Updating staff as to patients progress.
• Making sure that transition from hospital to home is smooth
• Educating patients on disease process and medication management
• Receiving verbal orders for home health and or DME
• Auditing charts for director
• Taking reports from clinicians and discussing patient care
• Providing suggestions to clinicians on ways to prevent patient re-admissions into hospitals
• Interpreting for Spanish patients.

• Transitions of Care nurse visiting patients in hospitals and or SNF
• Providing education and reviewing the patient what home health care services they will receive
• Working with facilities to reduce re admissions within 30 days of discharge by providing and starting home health care services within 24 hours
• Suggesting to providers services such as skilled nursing, Physical and Occupational therapy and DME as well as services that will be needed in order to prevent re-admission into the hospital
• Providing patients with disease case management and medication management
• Processing incoming referrals
• Triaging incoming phone calls from clinicians and patients with the on-call team
• Scheduling patients with the proper disciplines
• Remote position.

• Establishing case management and disease management for managed care patients
• Assisting in providing education seminars for patients with DM, COPD and CHF
• Managing patients that were hospitalized and following up with patients in order to make transition of care smooth
• Identifying high risk and non-compliant patients
• Working with the clinical team in order to prevent these patients form being admitted into the hospital
• Providing patients with the proper tools to empower them in the management of their conditions
• Ordering DME and or wound care supplies when necessary.

• Clinical and authorizations
• Assisted physicians with procedures such as bone marrow biopsies
• Administered injections to patients
• Venipuncture
• Authorizations for patients’ chemotherapy and medications
• Ordered chemotherapy for office
• Assisted patients with getting medications on the patient assistance programs
• Remote position

Managed support services for Eldercare program.

Reported changes to service coordinators in order to provide patients and caregivers the services necessary for them to remain at home. Evaluated home environment and provided education to patients and families. Provided and recommended home health services including skilled nursing, Traveled to patient's homes in 3 counties.