Merari Pimentel

· Built strong referral network by developing strategic relationships with general practitioners and internists.

• Enhances profits by engaging patients and assigning them for care coordination through CMA Brooklyn Health Homes or CCMP.
• Case conferenced with providers to confirm patients medical diagnosis, uploaded appropriate medica forms for patient
• Evaluated immediate needs, food, medical or shelter resources and connected patients to Community resources.
• Making referral to Agencies working with TEN Food bank
• Monitored eligibility through DOH - Mapps
• Gathered brief assessment and DOH consents remotely following the guidelines and maintaining the integrity of the agency and patients during the pandemic

• Reviewed each step of patient care and made proactive adjustments to avert issues.
• Established rapport and relationships with patients and external partners to cross-train and support medical staff.
• Update care plans in accordance with current regulations and guidelines.
• Encouraged patients to schedule recommended tests and procedures.
• Upheld confidentiality requirements and regulatory compliance guidelines.
• Worked closely with patients to deliver excellent and direct individualized patient care.
• Facilitated communication between hospital departments.
• Coordinated charitable, government and community resources for patients.
• Maximized preventive care utilization to reduce hospital burden and help eliminate readmissions.
• Updated documentation and reports detailing patient activities, care actions and hospital determinations.
• Met with patients and families to discuss care and plan of action for future.
• Assisted with and facilitated transition of care from hospitals, rehabilitation facilities and skilled nursing facilities to home.
• Consulted with medical staff and ancillary department to eliminate barriers to delivery of care and identified service delivery problems and potential for patient management intervention.

• Identified barriers when treatment goals not met, treatment plan not followed or important appointments missed and collaborated with team to assign care coordination team.
• Utilized knowledge of available resources to help patients select appropriate courses and obtain relevant support.
• Assisted patients in understanding individual rights and responsibilities in regards to care.
• Assisted patients in scheduling doctor and healthcare appointments.
• Participated in regular team meetings, huddles, staff meetings and quality improvement projects to improve patient care.
• Managed large caseload of patients in Health Homes Outreach department.
• Responded to patient concerns and questions with compassionate and knowledgeable service.
• Collected and reviewed patient information to assess eligibility for special programs.