Melanie Rivera

• Collaborates with the interdisciplinary team in the ED for post-discharge arrangements and will work with external entities to obtain and negotiate resources to meet patient needs, as necessary
• Interviews patients/families to complete an initial discharge assessment and to evaluate current support systems available to the patient and family, when patients are referred by the ED clinical staff
• Applies knowledge of community resources to the development of an appropriate discharge plan
• Utilizes information obtained from information systems, along with professional judgment, to help identify patients for further screening of potential discharge needs, if available and appropriate
• Appropriately prioritizes cases according to assessed needs, per Care Management Department policy.

• Perform telephonic and onsite assessments of medically complex pediatric recipients in the PDN/PPEC coordinate the care program
• As part of the multidisciplinary team, regularly meets with the team and contributes to the development of a comprehensive plan of case based on the needs of the patient and family
• Evaluates and modifies the plan of care as needed
• Regularly communicates changes to the family, healthcare team, and other agencies involved
• Collaborates with the family and healthcare team to arrange for identified home care needs and PPEC needs
• Consults on patient care issues in area(s) of expertise
• Functions as a resource to the community in areas of expertise
• Documents all patient care activities appropriately
• Manage daily workload associated with quality review process, including facilitation of case assignments and follows up to ensure that all cases requiring additional assistance or coordination are completed within timelines required by contract
• Prioritizes and addresses requests and assignments in a professional manner to develop cooperative relationships and to ensure that customer confidentiality is assured
• Maintains system for tracking all incoming and outgoing correspondence in accordance with timelines and requirements of contract
• Reviews documentation and prepares outgoing correspondence and notifications to physicians and provider representatives in accordance with policy and contract requirements
• Assists with the coordination and facilitation of Physician Peer to Peer conferences as necessary
• Review incoming referrals and peer determinations and directs questionable referrals and/or determinations to appropriate manager for follow up
• Functions as expert resource to external customers
• Actively participates in ongoing development, implementation, and evaluation of effectiveness of the program process, and works with management staff to formulate recommendations for process modifications when indicated
• Actively participates in internal initiatives, functioning as expert resource for other staff
• Participates in gathering information/data for CMS reporting
• Provides courteous and prompt service to all internal and external customers
• Identifies opportunities and recommends methods to improve service, work processes and financial performance
• Assists co-workers in the completion of tasks and assignments to ensure continuity of service and contract compliance
• Actively supports teamwork throughout the company.

For DCF staffing (behavior staffing and CMAT staffing) I attend and actively partici-pate in case staffings conducted by the DCF Child Protection Team.
• Help identify and recommend available services and resources that are effec-tive in addressing behavioral health issues or conditions that may lead to med-ical neglect allegations.
• Check Medicaid enrollment in the MMIS system and enroll the recipient in eQSuite Care Coordination DCF referral program.
• Provide Care coordination for the DCF Child Protection Team referrals.
• Call the guardian or targeted case manager within 1 business day of receiving referral.
• If the recipient is institutionalized, I provide community transition coordina-tion in collaboration with the DCF team and the Acentra Health's Medical Di-rector of Behavioral Health.
• Track meetings and clinical information received by uploading documents in the recipient’s chart in eQSuite care coordination system.
• Communicate with the recipient/guardian and DCF team as needed. The POC will be updated as needed in coordination with Acentra Health’s Medical Director of Behavioral Health.
• If all clinical/social needs of the recipient are met, the recipient is disenrolled from care coordination.
• Provide aging out coordination as needed if the recipient remains enrolled in Acentra Health Care Coordination program by age of 20.

• Collaborates with the interdisciplinary team in the ED for post-discharge arrangements and will work with external entities to obtain and negotiate resources to meet patient needs, as necessary
• Interviews patients/families to complete an initial discharge assessment and to evaluate current support systems available to the patient and family, when patients are referred by the ED clinical staff
• Applies knowledge of community resources to the development of an appropriate discharge plan
• Utilizes information obtained from information systems, along with professional judgment, to help identify patients for further screening of potential discharge needs, if available and appropriate
• Appropriately prioritizes cases according to assessed needs, per Care Management Department policy.

• In the absence of the Manager, escalates all issues up to their immediate supervisor
• Ensure staff is present and conducts daily rounds on each service line to assist to barriers/escalations
• Utilizes knowledge of operational expectations for all employees on the unit and exercises independent judgment to make recommendations to the manager for improvements
• Mentors the employees in a manner that develops the employees to their optimal level of performance to ensure competency in care management delivery
• Assesses patients for clinical and social needs
• Plans for delivery of care management to the patient and evaluates the outcomes of care delivered
• Ensures the patient experience is the focus of all services
• Monitors and leads staff in relation to established processes and outcome measures.

• Coordinates with the RN Case Managers for post-discharge arrangements and advocates for the patient in obtaining and negotiating resources to meet patient needs, as necessary
• Interviews patients/families to complete a thorough and timely psycho-social assessment and to evaluate current support systems available to the patient and family
• Collaborates with the RN Case Manager to address barriers that may impact or delay the patient’s discharge plan
• Performs discharge planning/post-acute care coordination
• Adapts quickly to changes in patient status and will update the assessment and discharge plan as the patient’s situation warrants
• Stays abreast of changing social work clinical trends, regulatory matters and third party payer requirements related to discharge planning and precertification of aftercare benefits.

• Provide case management and clinical supervision to teams delivering foster care and related services within CBC
• Teams may include therapist, foster parents, primary caregiver, guardian ad litem and other appropriate professionals
• Supervision will focus on the safety and permanency of the children and attainment of specific performance standards and outcomes.

• Provide therapeutic intervention services to children, adolescents, and adults using individual, family, and group treatment
• Coordinated and provided community-based substance abuse prevention counseling to adolescents, including the ARF program, Center for Drug Free-Living, Drug Court and CHRYSALIS Health Orlando for parents
• Visit individuals in homes or attend group meetings to provide information on agency services, requirements and procedures
• Attend court hearings due to the relevance of the cases
• Provide the court with the following documents: dispositions, status reports, case plans and judicial reviews
• Transport and accompany clients to shopping area and to appointments, using automobile
• Consult with supervisor concerning programs for individual families
• Complete referral forms dealing with: parenting, anger management, domestic violence, substance abuse and physical abuse
• Create family assessments to retrieve background of the specific case
• Create home studies to reunify families or place child in a relative or non-relative home
• Counseled individuals, families, and groups
• Provided 24-hour crisis intervention
• Placed children in foster care
• Advocated at the state and local levels for runaway program funding
• Spoke to schools and community organizations about parenting and adolescent issues.