- Assess and manage patient care needs, ensuring that the right resources and interventions are in place.- Collaborate with physicians, nurses, therapists, and other healthcare providers to develop comprehensive care plans.- Monitor and evaluate patient progress and adjust care plans as necessary to ensure optimal health outcomes.- Provide guidance and support to patients and their families, helping them navigate the healthcare system and make informed decisions about treatment.- Assist in the transition of care for patients moving between different healthcare settings (e.g., hospital to home/SNF, hospital to home).- Advocate for patients to ensure they receive timely and effective care, addressing any barriers to treatment.- Partner with community resources to coordinate services and arrange durable medical equipment, ensuring a safe and effective discharge plan.- Maintain accurate, up-to-date documentation of patient interactions, care plans, and outcomes.- Contribute to quality improvement initiatives and work to enhance the patient experience.

- Assess annual psychosocial, KDQOL, and PHQ-9 assessments for dialysis patients with caseload of 120+ (90% Hispanic population)- Provide resources covered under patient’s insurance to assist with psychosocial issues that may impact patient’s treatment - Conduct Social Worker Counseling sessions- Maintain concise and appropriate documentation- Attend physician rounds - Participate in monthly facility health report meetings- Make transplant referrals- Home Ambassador and Fun Champion Ambassador - Make APS, CPS reports as needed

- Conduct BioPsychoSocial Assessments - Coordinate Discharge and After Care Plans- Complete Family Sessions as Ordered by Psychatirsts - Provide Emotional Support to Patients and their Families- Attend and Advocate for Patients in Court Hearings - Check-in with patients - Assist in Identifying Coping Skills - Complete Clinical Documents for Every Patient Interactions and Collateral Contacts

- Conduct BioPsychoSocial Intake Assessments - Discharge and Aftercare Planning - Develop a plan for Group sessions- Lead Group Sessions- Manage collateral contacts - Attend and advocate for patients in Court Hearings - Check-in with patients - Document all patient contact

- Managed 90+ clients with their biopsychosocial status assessments- Designed, Communicated, and Coordinated with other organizations to further serve clients’ unmet needs- Monitored client’s care plans- Conducted community outreach to older adults in the community- Researched and provided useful resources for clients and their families - Prepared/Organized team meeting events- Authorized payments for vendors- Translated documents/interpreted phone calls for Korean clients - Assisted supervisor and other team members in maximizing the efficiency of serving clients in the community

- Developed weekly learning plan for the client- Observed and evaluated client’s progress and discuss in order to provide guidance catered to the client

I have performed the same duties as shown above for Pierce County Aging & Disability Resources.

As an intern at PCADR, I shadowed and completed biopsychosocial assessments, contacted clients to monitor contacts, and went on home visits to assist with providing resources.

- Scheduled chiropractic & massage therapy appointments- Billed insurance companies - Organized patient’s medical documents