Rachel Reyes
Philadelphia,PA
Summary
Accomplished Licensed Social Worker with a robust background in case management and patient education, notably at Jefferson Health Plans (formerly Health Partners Plans). Expert in developing care plans and enhancing health outcomes through multidisciplinary collaboration and organizational skills. Proven track record in improving patient independence and managing comprehensive assessments to meet diverse needs. Professional with strong background in care coordination. Skilled in patient advocacy, healthcare planning, and resource management. Known for effective team collaboration and achieving measurable results. Adaptable to changing needs with robust communication and organizational skills. Reliable and focused on delivering high-quality care outcomes.
Overview
11
11
years of professional experience
1
1
Certification
Work History
Field Based Care Coordinator, Medicare
Jefferson Health Plans
08.2017 - Current
- Conduct home visits to Medicare members primarily in Philadelphia area to create individualized care plans and assist with coordination of member-focused care
- Complete annual assessments with members to identify risks and barriers to care
- Conduct regular evaluations of care plan effectiveness, making necessary adjustments based on feedback from patients and providers.
- Maintain accurate and up-to-date documentation of patient records in accordance with HIPAA regulations.
- Educate members and caregivers on maintenance of chronic conditions, promoting independence and empowering them to manage their health conditions.
- Provide case management to schedule medical appointments, order durable medical equipment, and assist with obtaining other needed services in order to improve members’ health outcomes
- Develop strong relationships with community partners, facilitating referrals and collaboration on behalf of members.
Service Coordinator
Philadelphia Corporation for Aging
01.2016 - 08.2017
- Completed annual reassessments for participants (ages 60+) using appropriate care management tools to determine appropriate level of care and eligibility for Aging Waiver program
- Created and implemented service plan to coordinate necessary supports for nursing home eligible patients to remain safely in home
- Monitored case load of 60 patients through regular home visits and monitoring phone calls to ensure their health and safety goals were met by waiver program services
Social Work Intern
Samaritan Healthcare and Hospice
08.2014 - 05.2015
- Completed biopsychosocial assessments for incoming terminally ill patients to assess emotional/concrete needs and caregiving situation of patients and families
- Conducted weekly home visits to hospice patients to provide support and connect families with needed community resources for enhancement of spiritual, emotional, physical, and financial well-being
- Contributed to multi-disciplinary team to coordinate care of patients and ensure highest possible quality of life
Social Work Intern
Services & Advocacy for GLBT Elders (SAGE)
08.2013 - 05.2014
- Provided case management to clients (ages 60+) of LGBT senior center to help apply for public benefits, obtain housing, and complete other concrete tasks
- Counseled clients to set and complete goals in order to help them maintain independence
- Managed Lend-A-Hand program to connect vulnerable elders in the community with volunteers in order to help them with errands, escort them to essential appointments, and ease isolation
Education
Master of Social Work -
Fordham University
New York, NY01.2016
Bachelor of Arts - Social Work
Fordham University
Bronx, NY01.2014
Skills
- Licensed Social Worker
- Case Management
- Documentation
- Patient Education
- Organizational Skills
Spanish
- Medical terminology understanding
- Documentation proficiency
- Multidisciplinary team collaboration
- Goal Setting
- Policy Adherence
Accomplishments
- Managed a caseload of between 80 (field) and 350 (telephonic) members.
- Piloted department's first field case management program in 2018.
- Assisted with development of policies, norms, and expectations of field program.
- Organized and completed independent project to reach chronically unreachable members with an average of 40% reach/success rate, contributing to completion of HEDIS measures.
- Mentors and trains new employees as needed on ongoing basis.
Certification
Licensed Social Worker (Pennsylvania)
Languages
Spanish
Full Professional
Timeline
Field Based Care Coordinator, Medicare
Jefferson Health Plans
08.2017 - Current
Service Coordinator
Philadelphia Corporation for Aging
01.2016 - 08.2017
Social Work Intern
Samaritan Healthcare and Hospice
08.2014 - 05.2015
Social Work Intern
Services & Advocacy for GLBT Elders (SAGE)
08.2013 - 05.2014
Bachelor of Arts - Social Work
Fordham University
Licensed Social Worker (Pennsylvania)
Master of Social Work -
Fordham University
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