Rebecca Ross
Transition Care Coordinator
Greeneville,TN
Summary
Highly skilled professional with over 20 years of experience in the human service and healthcare fields. Possessing advanced critical thinking abilities and strong leadership qualities, I am eager to utilize my skills, education, and experience in a challenging opportunity. Committed to gaining new knowledge and skills to better serve the community, I am seeking to be part of an organization that fosters both professional and personal growth. Known for my exceptional organizational skills and self-motivation, I am adaptable to working independently or collaboratively as a valuable team member. With extensive knowledge of long-term service and supports, Medicaid, Medicare, and managed care, I bring valuable expertise to any organization.
Overview
21
21
years of professional experience
1
1
Certification
Work History
Transition Care Coordinator
Virginia Premier Health Plan/Sentara Health Plan
08.2017 - Current
- Manages all members who undergo transitions of the following: acute admissions , Nursing Facility (skilled or custodial to community)
- Participates in discharge planning for member's transition from acute institutional settings including, LongStay Hospitals, Nursing Facilities, and the community
- Provides support to care coordinators to maintain members in the community in lieu of transitioning to institutional settings as needed
- Assists the Utilization Review Team (medical and BH) in determining length of hospital stay as needed, and service recommendations
- Provides assistance and consultation to help decrease acute and emergency visits by high utilizers
- Serves on the ICT for all members who are in transition
- Facilitates communication and coordination between members of the health care team
- Educates the member, family or caregiver and members of the health care team about treatment options, community resources, insurance benefits, psychosocial concerns, care management, etc; so that informed decisions are made for discharge
- Encourages the member/patient to problem solve by exploring options for care, and alternative plans to achieve desired outcomes
- Strives to promote member self advocacy and self determination
- Acts as an advocate for member/patient
- Provides patient and caregiver with applicable disease process education to prevent a readmission
- Completes medication reconciliation
- Practices in accordance with applicable local, state and federal laws which govern confidentiality and medical information privacy regulations
Care Coordinator/Case Manager
Philadelphia Corporation for the Aging
07.2016 - 08.2017
- Assisted participants of the Medicaid funded Aging Waiver Program
- Ensured that each Participant had a care plan that met their needs and followed program guidelines and best practices
- Coordinated with service providers and ensure services are billed correctly
- Provided monthly monitoring phone calls, home visits and clinical reassessments according to program guidelines
- Completed applications for patients for Medicaid funded services, transportation and meals
- Provided referrals to other community resources
- Worked closely with other professionals to ensure quality care for each patient
- Ensured timely and accurate data entry
- Interviewed and evaluate Participants, including conducting safety and risk assessments
- Managed a case load of 65 Participants on an ongoing basis
- Completed daily documentation, maintaining monthly chart audits and weekly reports in accordance with CAO regulations
- Attended ongoing trainings related to Medicare/Medicaid, Service Coordination
Bridge Care Coordinator
Philadelphia Corporation for the Aging
04.2012 - 07.2016
- Assisted Medicare Fee for Service patients at time of discharge from Temple University Hospital for 30 days to prevent readmission
- Ensured that each patient had an appropriate referral for skilled home care and DME
- Coordinated follow up physician appointments and transportation
- Provided a home visit with detailed review of discharge papers, performed medication reconciliation, nutrition counseling and disease education
- Developed health care goals for an average of 65 patients each month
- Managed patient caseloads effectively, ensuring timely follow-up and appropriate interventions.
- Used company software and databases to maintain records of services performed and patient conditions.
- Developed strong relationships with community partners, facilitating referrals and collaboration on behalf of patients.
- Conducted regular evaluations of care plan effectiveness, making necessary adjustments based on feedback from patients and providers.
- Built strong relationships with clients to deliver emotional support and companionship.
- Maintained accurate and up-to-date documentation of patient records in accordance with HIPAA regulations.
- Educated patients on self-care strategies, promoting independence and empowering them to manage their health conditions.
- Assessed patient needs and connected them with appropriate resources to ensure optimal health outcomes.
- Monitored progress towards patient goals, adjusting care plans as needed to achieve desired results.
- Advocated for patients'' rights within the healthcare system, working diligently to address concerns or barriers to care.
- Monitored, tracked, and conveyed important patient information to healthcare staff to help optimize treatment planning and care delivery.
- Coordinated discharge planning, ensuring a smooth transition from hospital to home or other facilities.
- Provided emotional support for patients and families during difficult times, fostering resilience and coping skills.
- Facilitated appointments and transportation for patients, streamlining access to essential medical services.
- Determined need for special assessment activities for complex cases, effectively handling care plans.
- Implemented evidence-based interventions that improved overall patient satisfaction with the care process.
Assessment Worker
Philadelphia Corporation for the Aging
02.2004 - 02.2014
- Performed home visits with clients, families, and other professionals to perform clinical assessments to determine level and locus of care for clients
- Completed financial application for clients to apply for Medicaid funded services, transportation and meals
- Connected clients to needed services in their home or facility
- Advocated for client through referrals and resources
- Wrote concise, detailed clinical assessments on each client within mandated time frames
- Assisted to identify nursing facility residents who would be eligible to transition to the community
- Made reports and coordinated with APS when needed
- Attended Supervisory Training Spring 2005, Mentored six new hires, 'star' of the month October 2006
Education
B.A. - Applied Psychology, Human Services
Carson-Newman University
Jefferson City, TN05.2003
Skills
- Documentation
- Medical terminology understanding
- Documentation proficiency
- Multidisciplinary team collaboration
- Organizational standards
- Monitoring tools
- At-home care instruction
- Quality Assurance
- Patient education and counseling
- Medical Terminology
- Customer Service
- Problem-solving abilities
- Multitasking Abilities
- Reliability
- Professionalism
- Time management abilities
- Health Education
Accomplishments
I was chosen to represent my employer as a preceptor and attend ongoing preceptor training
Certification
Certified Case Manager through CCMC
Timeline
Transition Care Coordinator
Virginia Premier Health Plan/Sentara Health Plan
08.2017 - Current
Care Coordinator/Case Manager
Philadelphia Corporation for the Aging
07.2016 - 08.2017
Bridge Care Coordinator
Philadelphia Corporation for the Aging
04.2012 - 07.2016
Assessment Worker
Philadelphia Corporation for the Aging
02.2004 - 02.2014
B.A. - Applied Psychology, Human Services
Carson-Newman University
Certified Case Manager through CCMC
Similar Profiles
Thompson AcquahThompson Acquah
Senior Business Systems Analyst at Virginia Premier Health PlanSenior Business Systems Analyst at Virginia Premier Health Plan
KELLIE JIGGETTSKELLIE JIGGETTS
Organizational Change Management Lead at Sentara Health PlanOrganizational Change Management Lead at Sentara Health Plan
Kimberly (Hope) StrangeKimberly (Hope) Strange
Quality Assurance Coordinator at Sentara Health PlanQuality Assurance Coordinator at Sentara Health Plan