- Comprehensive management of behavioral health needs, including assessment, diagnosis, treatment and consultation- Provide transitions of care support via collaborative pathways with other patient care providers- Partner with the patient care team to identify and eliminate social determinates of healthcare- Participate in ongoing scheduled consultation with interdisciplinary team to monitor patient progress

- Partner with the patient care team to identify and eliminate social determinates of healthcare- Participate in ongoing scheduled consultation with interdisciplinary team to monitor patient progress

- Comprehensive management of behavioral health needs, including assessment, diagnosis, treatment and consultation- Provide transitions of care support via collaborative pathways with other patient care providers- Partner with the patient care team to identify and eliminate social determinates of healthcare- Participate in ongoing scheduled consultation with interdisciplinary team to monitor patient progress

- Worked to facilitate patient care by assessing patient needs, evaluating treatment options, creating treatment plans, coordinating care, and gauging progress- Successful in achieving the overall goal to improve clinical outcomes, increase patient satisfaction, and promote cost-effectiveness in the inpatient rehabilitation facility by creating processes and procedures

- Worked to prevent complaints and modify practices that cause repeated complaints by collaborating with supervisors, managers, and nurses- Resolved grievances by listening to patients and their families, directing them to physicians or supervisors, and developing a plan for acceptable resolution- Provided written responses to patients and families within the CMS time frame guidelines and provide accurate documentation in the MOS Data Base

- Completed psychosocial assessments, supported, and counseled pre- and post-transplant patients- Supported physicians and hospital personnel in providing optimal psychosocial support to transplant patients- Knowledgeable in ESRD/transplantation CMS/UNOS guidelines as well as various payer sources such as Medicare, Medicaid, VA and Employer Group Health Plans- Active participant in multidisciplinary meetings and possess strong commitment to team environment dynamics with the ability to contribute with proficiency- Coordinated with facility, doctor offices and dialysis clinics to develop new outreach efforts and provide improvements to existing outreach programs

- Coordinated communication between hospital and outpatient dialysis clinics- Provided dialysis education on different treatment modalities for new and existing dialysis patients- Participated in discharge planning with various members of the multidisciplinary team

- Maintained a caseload of 140 patients and connected patients with community resources- Completed psychosocial assessments monthly- Coordinated and participated in care plan meetings with multidisciplinary team members

- Supported a large caseload of clients with severe and persistent mental illness by completing treatment plans, meeting with clients for therapy and maintaining proper documentation- Facilitated psycho-education day treatment groups and assisted with psychiatric hospitalization of clients who were gravely disabled, or at risk of harming self or others- Responsible for legal court documentation for court ordered clients to remain in treatment and on medications

- Referred patients to outside agencies for needs identified in the discharge planning process- Planned and coordinated care of various patient populations, including mom and baby, orthopedic, general surgery and med surg, with hospital staff, nursing homes, long-term care facilities and home health agencies