Sowan Wortham

• Enrolled 2+ members daily through comprehensive 1-hour assessments, identifying needs and priority data.
• Built customized care plans for chronic health conditions affecting members living alone.
• Conducted daily outreach calls to 75+ Medicare members, promoting healthy living at home.

Educated members on disease management, contributing to lower hospitalization and emergency room visit rates.

• Completed post-discharge assessments and medication reconciliation, then faxed updates to providers for accuracy and Medicare compliance.
• Assessed members and closed HEDIS care gaps to support high star ratings.
• Supported care coordination by sending blood pressure cuffs, advance directive information, and digital scales for weight monitoring.
• Contacted providers for prescriptions and faxed requests for medical equipment, preventive screenings, and vaccines.
• Used OAR techniques to enhance member communication and understanding.

• Processed 485 Oasis plans of care for home health services using Homecare Homebased software, ensuring accurate and timely delivery of services to clients. Provided on-call triage nursing by answering urgent calls from active and pending clients after hours. Collaborated with on-call nurse to evaluate patients for ER or hospital admission, facilitating prompt medical interventions when necessary. Issued PRN orders for billing and documentation to facilitate home visits after working hours. Edited schedules for nursing and PT staff and made revisions for start of cares to accommodate the patient’s time and preferences.
• Coordinated patient assessments, care plans, and visit schedules across interdisciplinary teams.
• Processed 485 Oasis plans of care for home health services using Homecare Homebased software, ensuring accurate and timely delivery of services to clients.Provided on-call triage nursing by answering urgent calls from active and pending clients after hours.Collaborated with on-call nurse to evaluate patients for ER or hospital admission, facilitating prompt medical interventions when necessary. Issued PRN orders for billing and documentation to facilitate home visits after working hours.Edited schedules for nursing and PT staff and made revisions for start of cares toaccommodate the patient’s time and preferences.
• Reviewed clinical documentation for compliance with Medicare and agency standards.

• Conducted OASIS assessment to initiate home health services, ensuring comprehensive patient care. Coordinated IV therapy, facilitated blood work for lab delivery, replaced Foley catheters, and executed wound care. Delivered patient education on chronic disease management, enhancing understanding and adherence to care plans.
• Coordinated home health care plans for Delta patients across multidisciplinary teams.
• Assessed patient needs during Delta home visits and updated nursing care plans.
• Communicated with physicians, families, and Delta staff about patient status changes.

• Guided 75 members with chronic condition self-management at home, promoting timely health screenings through doctor visits.
• Informed members about medication side effects, safe dosages, and cost-effective options through local urgent care facilities.
• Scheduled follow-up appointments for members and coordinated home visits for those unable to travel.
• Completed NCQA assessments to verify home safety for ambulation, showering, and dressing, and contacted durable medical equipment providers for safety gaps.
• Referred cases to clinical access team when timely provider access was limited or when referral support was needed.
• Facilitated communication between medical benefits and pharmacy teams to review benefits that supported health and wellness.