Michelle Delgado
San Antonio,TX
Summary
Healthcare professional providing patient care coordination and transition planning across multiple healthcare environments. Leads discharge planning assessments and coordinates benefits navigation and resource referrals. Ensures follow-up to support safe, timely movement to subsequent care settings.
Overview
13
13
years of professional experience
Work History
Transition Specialist - Remote
Centene Corporation Superior Health Plan
San Antonio, TX
05.2024 - Current
- Partnered with care coordination and hospital case management teams to design effective transition plans for members discharging from rehabilitation or nursing facility settings to community care.
- Advised providers on ways to strengthen transition services and support continuity of care.
- Followed up with members after discharge to assess needs, address issues, and connect members with resources, service education, and benefit information.
- Performed transition of care assessments to validate care needs and route members to appropriate support services as needed.
- 9+ years.
LVN Medication Technician - Part Time
Franklin Park Senior Living
San Antonio, TX
09.2024 - 06.2026
- Monitored daily care of residents and managed caregiver assignments to ensure all duties were completed effectively. Recording, implementing physicians' orders, providing treatments and nursing procedures. Administered medications and maintained med cart, ensuring accurate documentation in the MAR. Responding to resident requests for care, reporting needs to families and providers. Responding to emergencies, incidents.
- Accumulated 2 years of hands-on experience in caregiving and resident support.
Service Coordinator - Remote
Centene Corporation Superior Health Plan
San Antonio, TX
01.2017 - 05.2024
- Using the Health Risk Assessment (HRA) and PHQ-9 Assessment (if needed) to screen members during in-home face to face or telephonic outreach to identify risk factors and needs. Facilitated access to necessary services for members with disabilities and behavioral health issues. Assist members in understanding their health plan and benefits. Assist members, if eligible in setting up in home personal assistance services (PAS) and/or day activity and health services (DAHS). Informed members about the significance of annual health screenings to promote preventive care. Follow up with members after recent ER visits or hospital stays to address any needs. Development of individualized care plans. Participate in Interdisciplinary Care Team Conferences. Assist members in finding new providers/specialists and setting up appointments. Assist members with setting up transportation. Assist members with finding resources such as housing, food pantries, and utility assistance. Partnered with PCPs and medical equipment companies to secure durable medical equipment (DME) for members. Educate members on managing health issues. Following up with members biannually and as needed to address questions/concerns or changes in condition.
- Gained nine years of expertise in assisting members with health needs.
- Coordinated member services for Superior Health Plan calls, referrals, and follow-up needs.
- Scheduled appointments with providers and community resources for Centene members.
- Reviewed service requests and routed cases through internal care coordination systems.
MDS Coordinator
Touchstone Communities
San Antonio, TX
01.2016 - 01.2017
- Utilized Minimum Data Set (MDS) assessment tool to ensure accurate reimbursement per state Medicare/Medicaid guidelines by capturing all care provided by staff. As an MDS coordinator, continued assessments of patients throughout their stay from admission to discharge are key. Ensuring assessments are completed timely and accurately. Developed Interdisciplinary Plan of Care and facilitated care plan meetings with care staff, patients, and families to ensure comprehensive care. Assisted in management of patient care. Trained and educated staff on documentation guidelines to enhance compliance and accuracy in patient records. Coordinated with care staff to ensure proper care of a resident by directing and delegating tasks. Attended daily morning meetings with department managers to discuss residents' pending admission and the status of current residents.
- Gained one year of experience in MDS coordination.
- Coordinated Minimum Data Set assessments across Touchstone Communities' skilled nursing settings
- Reviewed resident charts for accurate MDS documentation and clinical coding
- Scheduled interdisciplinary care plan meetings with nursing and therapy teams
MDS Coordinator/Reimbursement Nurse
Senior Care Centers
San Antonio, TX
01.2014 - 01.2016
- Utilized Minimum Data Set (MDS) assessment tool to ensure compliance with state Medicare/Medicaid guidelines, capturing all care provided by staff for accurate reimbursement. As an MDS coordinator, continued assessments of patients throughout their stay from admission to discharge is key. Ensuring assessments are completed timely and accurately. Developed interdisciplinary plan of care and facilitated care plan meetings with staff, patients, and families to ensure coordinated and comprehensive patient care. Assisted in management of patient care. Educated and trained staff on documentation guidelines. Coordinated with care staff to ensure proper care of a resident by directing and delegating tasks. Participated in daily morning meetings with department managers to review pending admissions and current residents' status, enhancing team communication and planning. Assisted by working the floor as a charge nurse. Participating in on-call rotation on weekends.
- Coordinated MDS assessments for Senior Care Centers skilled nursing residents.
- Tracked RAI schedules and maintained accurate assessment submissions.
- Reviewed resident charts for coding accuracy and care plan alignment.
- Gained 2 years of experience in skilled nursing care.
Education
Licensed Vocational Nurse -
Texas Careers/Kaplan College
San Antonio, TX01-2004
Medical Assistant -
National Institute of Technology
San Antonio, TX01-1997
Skills
Care transition planning
Care coordination
Patient assessments and vital sign evaluation
Clinical documentation
Care plan development and resource referral
Preventive care coordination
Chronic disease management
- Medication management
- Benefits navigation
- Care plan development and resource referral
Timeline
LVN Medication Technician - Part Time
Franklin Park Senior Living
09.2024 - 06.2026
Transition Specialist - Remote
Centene Corporation Superior Health Plan
05.2024 - Current
Service Coordinator - Remote
Centene Corporation Superior Health Plan
01.2017 - 05.2024
MDS Coordinator
Touchstone Communities
01.2016 - 01.2017
MDS Coordinator/Reimbursement Nurse
Senior Care Centers
01.2014 - 01.2016
Licensed Vocational Nurse -
Texas Careers/Kaplan College
Medical Assistant -
National Institute of Technology