Samonte Imelda

• Facilitated successful transitions from acute care settings to post-acute environments by coordinating with appropriate providers and services.
• Enhanced patient satisfaction by conducting regular assessments, addressing concerns, and promptly resolving issues.
• Promoted culture of safety by participating in quality improvement initiatives, identifying areas for improvement, and developing action plans.
• Served as liaison between patients, families, medical providers, and insurance companies to ensure efficient coordination of care resources when needed.
• Actively participated in interdisciplinary rounds to contribute valuable insights from a nursing perspective while discussing patient progress and care strategies.
• Evaluated patient experiences using survey data to identify opportunities for improving service delivery across all aspects of care provision.
• Monitored patients, evaluated results, and recommended further courses of treatment to quickly improve patient outcomes.
• Improved patient outcomes by implementing evidence-based clinical practices and providing ongoing education to nursing staff.
• Reduced hospital readmissions through thorough discharge planning and coordination with interdisciplinary teams.

Perform daily prospective, concurrent and retrospective review using evidence-based guideline criteria, (MCG and Interqual)and other information to determine appropriate level of care and readiness for discharge.

Utilize evidence-based practices and clinical guidelines to inform decision-making and improve patient outcome.

Advocate for patient and their families to ensure they receive the highest quality of care.

Manage complex cases, including those involving multiple comorbidities and social determinants of health.

Provide comprehensive care coordination and management for patient with complex medical needs.

Develop and implement individualized care plans that address patient physical, emotional and social needs.

Collaborate with interdisciplinary teams to ensure continuity of care and optimal patient outcome.

Worked closely with physician and Health plan regarding denials, facilitate appeal process initiate peer to peer as needed.

Worked with senior physician leaders when physician to physician conversation will require (Escalated cases to senior physician when MD to MD conversation is required)

Establish a partnership with a high-volume health plan including weekly calls to decrease denials, enhance communication, and to optimize timely authorization and insure re-imbursement.

Advised and support physician regarding documentation to support inpatient stay.

Establish a partnership with the physician to improve clinical documentation, reduce length of stay, and ensuring a safe discharge to the next level of care without delay in service discharge planning and transition.

Educated patients on available community resources and how to access them

effectively to prevent re-admission.

Participated in team meetings to discuss case management strategies for individual cases.

Participate on daily departmental huddles to create sustainable clarity and focus within the team to achieve LOS/organizational goals.

Collaborate with physician and department director to the development and

improvement of clinical care pathway that enhance cost effectiveness while providing quality care

Worked with community partners ( HH , SNF, Hospice ) to assist patient in safe and appropriate next level of care.

Support ED staff and physician in identifying unnecessary admission, arrange for appropriate referrals and follow up for outpatient service

Managed day-to-day workflow within the department, delegating tasks appropriately

when necessary.

Coordinated patient care activities between medical teams, providing guidance and

support to nursing staff

Utilize strong communication skills to collaborate effectively with staffs, physicians and

other healthcare professional

Ensure compliance with all applicable state and federal laws governing health care

facilities.

Assisted with recruitment efforts by interviewing potential candidates for open

positions in the Nursing Department.

Reviewed incident reports submitted by nursing staff members, taking corrective action

when necessary.

Initiated process improvements to enhance operational effectiveness while maintaining

quality control standards.

Demonstrated expertise in developing and managing nursing staff , ensuring high

quality patient

Participated in strategic planning initiatives to promote growth within the organization.

Established clinical direction for nursing care delivery, providing clinical supervision and

maintaining quality outcomes.

Advocated for patients and families, liaising with multidisciplinary teams.

Cooperated with other health care professional to develop and implement policies and

procedure that promote patient safety and quality of care

• Set schedules for staff to start and complete MDS assessments and care plan meetings.
• Ensured timely completion of all MDS assessments, maintaining full compliance with federal and state regulations.
• Maintained up-to-date knowledge on CMS guidelines and changes to ensure accuracy in reporting and reimbursement processes.
• Collaborated closely with therapy departments to accurately capture rehabilitation needs within MDS documentation, supporting appropriate resource allocation for residents'' needs.
• Enhanced patient care quality by implementing comprehensive MDS assessments and care plans.
• Verified prompt and accurate completion of MDS activities for billing.
• Collaborated with nursing staff to provide accurate and timely clinical assessments for each resident, leading to improved overall care.
• Provided ongoing education for nursing staff regarding MDS best practices, contributing to a knowledgeable and skilled workforce.
• Monitored changing regulations related to RAI/MDS requirements, keeping staff informed about updates that impact their daily work routines.
• Implemented interdisciplinary meetings focused on individualized care plan development, resulting in more targeted interventions and improved resident outcomes.