Rachel Guidi
Pittsburgh,PA
Overview
13
13
years of professional experience
Work History
Medical Social Worker
Preferred Primary Care Physicians
04.2021 - Current
- Communicate and collaborate with interdisciplinary team including complex nurse case managers, patient care coordinators, medical assistants, office staff, and physicians
- Telephonically complete comprehensive psychosocial assessment with patient and/or family to assess for need for services including all medical follow up, psychological assistance, housing, transportation, financial and nutritional support
- Coordinate and complete appropriate referrals to community agencies and follow up with patients and families to check status of referrals
- Ensures continuity of care through defined, evidence-based methods, including follow up to ensure the action plan is being implemented as documented, utilizes resources in a patient-centered and efficient manner, promotes and facilitates improved clinical outcomes and patient satisfaction
- Maintain professional working relationships with liaisons/marketers for personal care homes communities, hospice/palliative agencies, home health agencies, and various community organizations
- Document all communication with patients, families, and community providers in electronic medical record
- Utilize ENLI Care Manager and Medent EMR to track patients and care needs as well as document all communication, referrals, and resources provided to pt and family
- Maintain ongoing record of community resources for common concerns including utility assistance programs, prescription cost assistance, food insecurity assistance programs, transportation, and in-home services through local agencies
- Monitor program effectiveness at the point of care (e.g
- Physician offices) and provide feedback and training to office staff and physicians as needed.
Social Services Coordinator
Promedica (formerly Manorcare) Health Services Whitehall Borough
05.2017 - 04.2021
- Perform psychosocial assessments and complete social work care plan upon admission to facility
- Review and complete PASSR-ID for accuracy to identify if patient meets target criteria
- Perform Minimum Data Set evaluations, including BIMS and PHQ-9, and enter data into electronic charting system
- Facilitate patient and family care conferences along with interdisciplinary team to discuss patient's plan of care and discharge goals/planning
- Identify and coordinate appropriate community resources based on individual patient's needs
- Coordinate with Nursing Home Transitions program and Community Health Choice service coordinators to facilitate safe discharges back to the community
- Collaborate with interdisciplinary team to ensure appropriate discharge planning and recommend community/home services for patients and families
- Issue and review notices of Medicare non-coverage with patients and families
- Submit documentation to QIO for patient/family appeals
- Submit necessary orders and referrals related to discharge planning including but not limited to home health care or hospice services, durable medical equipment, home infusion, negative wound pressure therapy, home meal services, etc.
Youth Care Counselor/ Supervisor
Alternative Living Solutions
05.2011 - 05.2017
- Supervise youth counselors and youth care workers
- Attend court appointments, coordinate transportation, monitor and maintain required files
- Assist in State licensing visits and was responsible for HSIS and other DHS reporting functions
- Review youth's treatment plan progress with county probation officers,caseworkers, and families
- Improve youth care outcomes by implementing evidence-based practices and personalized interventions
- Implement behavior modification strategies to encourage positive choices among youth under supervision
- Establish strong rapport with youth, building trust and fostering open dialogue about personal issues and concerns
Education
Master's of Social Work -
PennWest California
California, PA05.2017
Bachelor of Science - Psychology, Criminal Justice
Kent State University
Kent, OH05.2012
Skills
- Experience with all Microsoft Office programs, Careport,Medent EMR, Tiger Connect, Point Click Care EMR, and ENLI Care Management System
- Ability to work effectively as part of a team or independently
- Experience in a remote position
- Knowledge of medical terminology and disease processes
- Interdisciplinary coordination with patient and family inclusion
- Healthcare navigation and referral coordination
- Psychosocial assessment and discharge planning
- Knowledge of community resources through county, state, and federal programs and local organizations
- Critical thinking and problem-solving abilities
- Active Listening
Licensure
Licensed Social Worker through the Pennsylvania State Board of Social Workers, Marriage & Family Therapists and Professional Counselors
References
Available Upon Request
Timeline
Medical Social Worker
Preferred Primary Care Physicians
04.2021 - Current
Social Services Coordinator
Promedica (formerly Manorcare) Health Services Whitehall Borough
05.2017 - 04.2021
Youth Care Counselor/ Supervisor
Alternative Living Solutions
05.2011 - 05.2017
Master's of Social Work -
PennWest California
Bachelor of Science - Psychology, Criminal Justice
Kent State University
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