Robin Woods

As Health Care Manager assume overall accountability for identification of members appropriate for care coordination and/or case management program services. Responsible for completion of comprehensive case management assessment and gathering pertinent information about members health needs from physicians, ancillary health professionals, and family as necessary. Additionally responsible for development of member's interdisciplinary individualized plan of care including short term and long-term goals. Monitor and evaluates members progress towards meeting goals and initiate appropriate interventions as necessary. Serve as advocate for member and act as liaison between member and other community-based agencies. care needs. Assist member in appropriate utilization of member's benefits and in coordinating with other payer sources. Job functions predominantly performed telephonically with occasional member meetings as situation necessitates. Managed average rotating flex caseload of 80 to 100 members.

Provide primary oversight and nurse case management services to case-mix of clients with disabilities age 60 and over and referred Veterans who require home health aide assistance due to deficits in performance of activities of daily living (ADL), and instrumental activities of daily living (IADL). Perform initial assessment and completion of plan of care (POC) in support of services to be provided in-home to client. Complete reassessment at defined timelines as detailed in organizational policies, and update POC as needed. Work closely with client's primary caregiver and triage clinical information as needed to client's medical provider. Responsible for caseload of 50-60 as part-time nurse case manager. Additionally, assist with home care aide supervision and in-service training needs. Actively identify additional clinical resources needed to support transition into home environment.

Recruited to work on part-time basis specific to Delmarva contract related to Personal Care Aide Services for residents of District of Columbia enrolled Medicaid program. Perform initial evaluation/patient assessment and render decision as to medical necessity and need for personal care aide services. Additionally, recommend appropriate number of personal care aide hours based on physical assessment outcome measures and complete formal computerized clinical document write-up.

Responsible and accountable for providing oversight/triage to patients in various outsourced community based programs who receive skilled medical/nursing care within VA contracted long-term care facilities, Community Residential Facilities-Assisted Living, Adult Day Health Care, and Home Health. Served as sole Community Health Nurse Case Manager for over five years within Community Services Branch. Nursing management responsibilities include caseload of over 300 patients within before mentioned programs. Perform onsite visits as part of VA inspection team responsible for making determinations of facility approval based on series of quality measures used to identify areas that require improvement or correction prior to VA contract approval and prepare written report. Perform onsite visits to veterans residing in various levels of VA approved facilities to monitor quality of care provided and patient/family satisfaction with facility. Serve as primary liaison triaging medical request back to VA hospital for medical staff caring for veterans in community facilities. Facilitate referral process for appointments in specialty clinics and arrange transportation from community facility to VA hospital. Responsible for timely documentation within electronic medical record. Work closely with various disciplines within VA healthcare system to assure continuity of care to veterans receiving outsourced community service