• Utilize monitoring, assessment, planning, intervention, and critical thinking skills to care for acute care patient populations in the home• Navigate patients and families across the continuum of the Acute Care at Home phases of care. Monitor and respond to biometric data per Acute Care at Home protocols• Ensure all interventions in the patient’s care plan are implemented efficiently with a patient-centered approach. Conduct home and audio/visual patient care visits as directed by the care team and/or protocol• Leverage the resources and expertise of the Acute Care at Home team and supplier partners to implement collaborative workflows, standards, policies, protocols, guidelines, and documentation systems to support safe, reliable, high-quality, evidence-based care with clinical protocols as the foundation• Adhere to the clinical protocols and be willing to obtain the necessary training to provide care within the context of the providing evidence-based care• Promote professional practice and a culture of safety; willingness to engage in process improvement efforts• Provide virtual protocol nurse-driven assessments, care coordination and interventions as appropriate informed by Acute Care at Home protocols for diverse patient populations and their families.

• Completes comprehensive assessments of members per regulated timelines and determines who may qualify for case management based on clinical judgment, changes in member's health or psychosocial wellness, and triggers identified in the assessment.• Develops and implements a case management plan in collaboration with the member, caregiver, physician and/or other appropriate healthcare professionals and member's support network to address the member needs and goals.• Facilitates interdisciplinary care team meetings and informal ICT collaboration.• Uses motivational interviewing and Molina clinical guideposts to educate, support and motivate change during member contacts.• Assesses for barriers to care, provides care coordination and assistance to member to address concerns.

Perform Skilled Nursing Facility (SNF) assessments on patients using clinical skills and appropriate measurement tools.Collaborate effectively with the patients’ health care teams to establish an optimal discharge Coordinate services between Primary Care Physician (PCP), specialists, medical providers, and non-medical staff Provide member and provider education, facilitate member access to community-based services as needed Monitor referrals made to community-based organizations, medical care and other services Assess and monitor patients’ continued appropriateness for SNF settingIdentify related risk management quality concerns and report these scenarios to the appropriate resources. Assure patients progress toward discharge goals and assist in resolving barriers.

Coordinates participants’ skilled care in their place of residence, working closely with medical clinic staff and rehab disciplines.Accepts referrals to include medical orders, document pertinent information required for initiation of services. Assists participant/family and physician in arranging for skilled. services in the participant’s place of residence. Utilize assessment skills and discretionary judgment to develop a plan of care. Coordinate services between Primary Care Physician (PCP), specialists, medical providers, and non-medical staff Provide member and provider education, facilitate member access to community-based services as needed. Monitor referrals made to community-based organizations, medical care, and other services. Actively participate in integrated team care management rounds with Medical DirectorsIdentify related risk management quality concerns and report these scenarios to the appropriate resources. Enter and maintain assessments, authorizations, and pertinent clinical information into various medical management systems.Direct care to participating network providers. Perform duties independently, demonstrating an advanced understanding of complex care management principles.Participate in case management committees and work on special projects related to case management as neededAudit daily notes entered in EMR by field staff, upon completion of medical record audit, compiles detailed findings.Audit staff in accordance with established auditing processes established and assist in making recommendations for improvement to the Home Health DirectorAssist the Training team to incorporate compliance and audit findings into training programs.Assist with revisions to Policy and Procedure and/or work process development based on audit finding.

Perform care management duties to assess, plan and coordinate all aspects of medical and supportive services across the continuum of care for select members to promote quality, cost effective care. Assess the members current health status, resource utilization, past and present treatment plan and services, prognosis, short and long-term goals, treatment and provider options. Utilize assessment skills and discretionary judgment to develop plan of care. Coordinate services between Primary Care Physician (PCP), specialists, medical providers, and non-medical staff Provide member and provider education, facilitate member access to community-based services as needed. Monitor referrals made to community-based organizations, medical care and other services. Actively participate in integrated team care management rounds with Medical DirectorsIdentify related risk management quality concerns and report these scenarios to the appropriate resources. Enter and maintain assessments, authorizations, and pertinent clinical information into various medical management systems.Direct care to participating network providers. Perform duties independently, demonstrating an advanced understanding of complex care management principles.Participate in case management committees and work on special projects related to case management as needed.

Coordinated the transition of care between inpatient Members to other settings with practitioners, Healthcare Services (HCS) staff, community-based agencies, social workers, hospital/nursing facility discharge planners, and/or other providers as required.Conduct assessments and responsible for safely and effectively transitioning members from acute or inpatient care to lower levels of care and/or home in a cost-efficient manner. Plan, implement, coordinate, monitor, and evaluate the services for members as they transition care. Conduct onsite hospital discharge visits and post-discharge visits to assure continuity of care. Promote the integration of services for members including behavioral health and long-term care.The goal is to reduce the member’s hospital admissions and readmissions for preventable treatment anddisease complications and assist in the coordination of physician’s treatment plan, consistent with the member’s benefits.Obtained a strong knowledge of HEDIS and Quality Measures and STAR ratingsResponsible for knowing Medicare and Medicaid Guidelines, benefits, policies and contractual obligations.SME-Mentored/Trained new Transition of Care Coaches, ensured new ToC’s were educated to follow all policies and workflow as per contractual obligations.

Conducted comprehensive Initial Assessment of member’s health with Complex health needs and determined who may qualify for case management based on clinical judgment, changes in conditions, health triggers in assessment, or psychosocial wellness.Managed Complex cases for Pediatric Members, Transplant Members, and Multiple Co-Morbidity complex Members.Development of an individualized care plan in conjunction with members to meet their healthcare needs.Facilitation of member referrals to resources in the communityFollow-up and communication with members regularly to monitor needs.Developed a systematic approach to assessing, planning, and provision of case management services to improve health outcomes.Conducts face-to-face or home visits as required.SME-Mentored/Trained new Complex Case Managers, ensured new CCM II were educated to follow all policies and workflow as per contractual obligations. Performed random audits on CCM cases to ensure compliance and reported findings to Supervisor and conducted coaching and re-training if needed.

Responsible for coordinating all aspects of the interdisciplinary care and services provided to hospice patients and their families Collaborates with the patient, family, and the other members of the Hospice interdisciplinary team to develop and implement a care plan for the patient. Utilize all basic nursing skills, including but not limited to nursing assessment, current symptom management knowledge, patient/caregiver teaching, documentation, and promoting comfort on a daily basisReceive and respond to inquiries about hospice care.Obtain all necessary intake information and physician’s start-of-care order.Assist in obtaining needed equipment and supplies to begin care.Maintain accurate tracking records and log of daily activities.Clarify all medications with the pharmacy and attending physician during admission.Review medications with patient and family.Provide extensive teaching with patient/family on symptom management and the disease process to ease anxiety.Perform after-hour admissions as needed.

Performed initial assessment of critically/hemodynamically unstable patients and monitor changes in condition.Consulted and coordinated with health care team members to assess, plan, implement and evaluate patient care plans.Monitored and adjusted specialized equipment used for patients, and interpreted and recorded electronic displays results, such as intracranial pressures, central venous pressures, pulmonary artery pressures, and cardiac rhythms from cardiac monitors, respirators, ventilators, manometers, oxygen pumps, etc. and reported to Physician.Initiated patient education plan, as prescribed by physician. Educated patients and significant others how to manage their illness/injury, by explaining: post-treatment home care needs, diet/nutrition/exercise programs, self-administration of medication and rehabilitation.Functioned as a Patient advocate and acted like a liaison between the patient’s, patient’s family and other healthcare team members.Worked alongside Critical Care Team Physicians to implement plan of care accordingly.Mentored and Trained Graduate Nurses Precepted Nursing Students for Acute Care Rotation

Worked directly with Vice President of Clinical and Provider Relations coordinating the daily operations of the department.Assisted in Network development and overseeing a network of over 900 providers.Implement and monitor all procedures and activities related to credentialing, re-credentialing and contracting of network providers.Solid knowledge of NCQA and DHS credentialing standards.Assemble and prepare credentialing information for appropriate committees.Review managed care contract language and negotiating language to meet agreed to parameters with legal counsel to lessen risk and improve operational efficiencies. Negotiate provider reimbursement for free standing facilities, physicians and ancillary providers.Prepare financial reports and provider and service contracts for the VP.Act as external and internal network liaison.Assist with Hospital Contracting Issues

Managed approximately 250 clients whom consisted of Elderly, Children with both Mental and Physical disabilitiesManaged more than 150 home health aids providing service plans to clients.Managed, orientated, and train attendants in tasks delegated by the DHS Plan of Care while making any recommendations to their Case Worker on progress or modifications needed.Outreached different organizations in the community to assist with resources for the clients.