Priscilla Johnson, RN BSN
Registered Nurse
Summary
Dedicated and caring Registered Nurse with superior communication and critical care skills combined with a broad range of healthcare experience with managed care case management, home health, and care coordination. Hardworking and energetic leader with the ability to create/ maintain a positive working environment that uplifts spirits. Diligent, caring, and knowledgeable in the diverse field of nursing. Knowledgeable about EMR charting, care coordination, care plan development and interdisciplinary collaboration focused on optimizing patient care and support. Quality-focused and efficiency-driven leader.
Overview
18
18
years of professional experience
1
1
Certification
Work History
RN Care Manager II
Health Services for Children with Special Needs (HSCSN)
01.2022 - Current
- Manage caseload of 85 pediatric and young adult population as outlined by CASSIP and HSCSN Care Management Leadership
- Conduct thorough assessments of health needs, strengths, and risks to coordinate appropriate interventions and support services.
- Maintain compliance in accordance with contractual and care management requirements
- Assist in research, and implementation of disease management/population health programs to serve our highest complexity members
- Conduct outreach and face-to-face visits at frequency no determined by enrollee's assigned stratification level or more if needed, with each enrollee/caregiver virtually, in their homes, physician's offices, or other mutually agreed upon locations
- Assess enrollees determined by enrollee's stratification level to identify needs/barriers and close gaps in care
- Identify over/under utilization promptly and take appropriate action according to organizational policy
- Asses medical, mental/behavioral health, environmental, psychosocial and educational information, then develop, implement, and update accurate individualized comprehensive care coordination plan for each assigned enrollee in collaboration with PCP and/or other multi-disciplinary team members including public agencies
- Complete routine care coordination and care management activities with attention to quality, timeliness and in compliance with company policy and national standards
- Consult with Senior Care Manager to review and prioritize cases, set objectives, identify, and report potential risk and utilization concerns
- Understand and abide by HSCSN's Confidentiality policy and procedure regarding enrollee specific information
- Clearly and respectfully communicate verbally and in writing
- Assist assigned enrollees and their caregivers in understanding importance of EPSDT and compliance with all health services
- Strive to achieve target rate of compliance for preventive medical and dental services
- Assist with scheduling and monitor compliance of mental health/medical appointments
- Follow department policies for identifying and reporting noncompliance, missed appointments, and other reportable incidents including communication to primary care provider or specialist
- Apply advanced knowledge of conditions of target population/standard approaches to care management and care coordination to assigned enrollees
- Facilitate multidisciplinary meetings as necessary, including off-site meetings with other involved agencies
- Educate enrollee/caregiver on appropriate vendor(s) on DME/assistive technology use
- Facilitate transitions of care to include but not limited to transitioning from Early Intervention to DCPS; from pediatric to adult providers; transitioning out of HSCSN when enrollee ages out or is disenrolled for any reason; from outpatient to inpatient or reverse; and entering or exiting custody of CFSA, DYRS or any type of institutional care
Home Health RN Case Manager
Part Time Contractor VMT Home Health Agency
01.2020 - Current
- Managed complex cases involving multiple medical conditions, resulting in more effective care coordination and improved patient outcomes for adult and geriatric populations.
- Mentored new nurse case managers, sharing expertise in field practices and promoting ongoing professional development opportunities.
- Facilitated smooth transitions between care settings by coordinating with other healthcare professionals and communicating effectively with patients and families.
- Advocate for clients' needs within the healthcare system, securing necessary resources and services to improve overall health outcomes.
- Comfortable with work in a fast-paced environment with frequently changing priorities, deadlines, and workloads that can be variable for long periods of time.
- Enhanced patient safety by conducting regular assessments and promptly addressing any signs of decline or potential complications.
- Ability to meet established deadlines and handle multiple customer service demands from internal and external customers, within set expectations for service excellence.
- Assessed fall risks among the elderly population, implementing targeted prevention strategies to reduce injury occurrences.
- Identify barriers in treatment plans and provide nursing education/ interventions to families to assist with self-management.
- Implement evidence-based practices in geriatric care management, staying current on industry trends and best practices to provide exceptional service to clients.
- Conduct initial and ongoing assessments utilizing nursing assessment skills in a home setting
- Serve as a liaison between clients, families, and healthcare providers to facilitate communication and promote understanding of complex medical information.
- Facilitate professional relationships with local agencies to facilitate referrals and access to additional support services for patients in need.
- Identify and prioritize gaps to develop plan of care and short and long-term goals to empower consumers to meet identified goals.
- Identify appropriate interventions and resources to meet gaps (e.g., psychosocial, transportation, long-term care) based on specific consumer needs from both the health care and psychosocial / socioeconomic dimensions of care
- Document the plan of care in appropriate EHR systems and enter data per specified format
- Maintain consumer engagement by establishing rapport, demonstrating empathy, and building a trusting relationship
- Collaborate with primary providers or multidisciplinary team to align or integrate goals to plan of care and drive consistent coordination of care to facilitate continuity of care.
- Reassess plan of care at appropriate intervals based on initial objectives, significant change of condition, or achievement of goals.
- Educated clients and families on community resources, treatment options and health care services to better manage conditions.
- Conducted home visits to assess safety risks and recommend modifications, promoting independence for elderly clients.
- Reduced hospital readmissions through diligent monitoring of patients'' progress and timely interventions in-home settings.
Registered Nurse Care Coordinator
Children's National Medical Center, CNMC
01.2016 - 01.2022
- Provide health education based on patient /family learning preferences throughout patient's disease trajectory or health promotion; utilize expertise in cultural competency to enhance relationships, processes, and outcomes for patients/families
- Enhanced patient satisfaction through effective communication, empathy, and timely response to their needs.
- Collaborated with interdisciplinary teams for comprehensive patient care plans, resulting in better health outcomes.
- Engage opportunities to act in best interest of patient/family, building trust and confidence, while upholding moral and legal standards of due care
- Coordinate mechanisms across systems, institutions, and community to provide continuity of care for wellness needs or health concerns; direct and participate in development of patient care policies and protocols in order to advise and guide practice
- Ensure regulatory requirements are met and area is in a constant state of readiness in area of practice; keep update on application of health informatics systems such as diagnosis and treatment technology linked to patient care
- Employ critical attributes of effective collaboration to create, promote, and maintain environment that supports successful partnership and high-performance team outcomes
- Facilitate interdisciplinary patient care rounds/conferences to review treatment goals and optimize outcomes
- Communicate and escalate clinical/administrative issues as appropriate to levels of individuals assigned for resolution
- Participate in peer review for staff.
- Evaluated success of care coordination efforts by tracking patient progress and outcomes over time.
- Assisted in development of departmental policies and procedures related to care coordination practices.
- Facilitated communication between patients, families, and healthcare teams for seamless transitions of care across settings.
- Maintained detailed documentation of patient interactions and interventions, facilitating clear communication among healthcare professionals.
- Reduced hospital readmissions through effective discharge planning and patient follow-up.
- Conducted regular assessments of patient needs and available resources, adapting care plans accordingly for continued progress toward wellness goals.
- Served as a liaison between patients, insurance companies, and providers to help navigate complex healthcare systems for optimal outcomes.
- Promoted interdisciplinary collaboration through regular meetings and information-sharing sessions with members from various departments involved in patient care.
- Collaborated with physicians to develop comprehensive treatment plans, addressing both physical and psychosocial needs of patients.
- Managed caseloads of patients with complex medical conditions, ensuring timely access to appropriate care and services.
- Administered medications via oral, IV, and intramuscular injections and monitored responses.
- Collaborated with physicians to quickly assess patients and deliver appropriate treatment while managing rapidly changing conditions.
- Administered medications and treatment to patients and monitored responses while working with healthcare teams to adjust care plans.
- Educated patients, families and caregivers on diagnosis and prognosis, treatment options, disease process, and management and lifestyle options.
- Mentored new case managers, sharing valuable insights from years of hands-on experience in the field.
- Provided emotional support to patients during challenging times, fostering a sense of trust and rapport that contributed to better overall wellbeing.
- Coordinated discharge planning efforts with social workers, case managers, and other multidisciplinary team members for smooth transitions post-hospitalization.
Registered Nurse, Medical-Surgical Unit
Medstar Washington Hospital Center
08.2006 - 02.2016
- Collaborated with interdisciplinary teams for optimal patient care, ensuring seamless communication between healthcare providers.
- Consistently maintained accurate documentation of patient assessments, interventions, and outcomes in accordance with regulatory requirements.
- Skillfully performed venipuncture, IV insertion, and catheterizations, ensuring proper technique and adherence to infection control standards.
- Provided health education to patients and families regarding discharge instructions and plans of care.
Education
Bachelor of Science - Nursing
Chamberlain University
Arlington, VA05.2018
Associate of Nursing Degree - Nursing
University of The District of Columbia
Washington, DC05.2006
Skills
- 10 years experience with serving the Medicaid population
- Able to effectively address the needs of diverse constituencies
- Community and Home Health experience
- CRISP/ QNXT/ CVS Caremark/ OASIS/ DC Health Connect experience
- EPIC/ Guiding Care/ Cerner experience
- 5 years Case management experience
- Well organized, flexible, and action-oriented
- Proficient in the use of web-based technology, Google Docs, and Microsoft Office applications such as Word, Excel and PowerPoint
- Conducive to working in a fast-paced environment with frequently changing priorities, deadlines, and workloads that can be variable for long periods of time
- ICU/ ER Level One Trauma Experience
- CPR Certified
Certification
- CPR
- Certified Parent Educator
Work Availability
monday
tuesday
wednesday
thursday
friday
saturday
sunday
morning
afternoon
evening
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Quote
A cheerful heart is good medicine
Timeline
RN Care Manager II
Health Services for Children with Special Needs (HSCSN)
01.2022 - Current
Home Health RN Case Manager
Part Time Contractor VMT Home Health Agency
01.2020 - Current
Registered Nurse Care Coordinator
Children's National Medical Center, CNMC
01.2016 - 01.2022
Registered Nurse, Medical-Surgical Unit
Medstar Washington Hospital Center
08.2006 - 02.2016
Bachelor of Science - Nursing
Chamberlain University
Associate of Nursing Degree - Nursing
University of The District of Columbia
- CPR
- Certified Parent Educator
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