Oversaw transitions of care management between patient settings with the objective of improving quality outcomes and decreasing utilization costs by reducing readmission rates. Coordinated follow up care for members, educated members about their conditions, utilized motivational interviewing to promote change behavior and helped patients navigate the healthcare system. Improved performance on transions of care targets by 50%.

Liaised with members and completed MDS and comprehensive assessments accurately to achieve accurate reimbursement rates. Utilized motivational interviewing with members to identify workable goals and formulated care plans based on this information.

Provided medical care management to a panel of members ages 21 to 64. Conducted comprehensive assessments, including MDS documentation and developed and implemented care plans. Identified barriers to care and advocated for members with their health team.

Promoted home infusion services to case managers, physicians, home heath agencies, and other referral sources to grow business. Coordinated discharges of patients needing IV therapy, including hospice management, antibiotics, total parental nutrition and enteral therapy in the home setting.

Provided comprehensive nursing care to patients on a general medical and surgical unit. Fulfilled role of charge nurse when assigned, delegated work assignments to staff and organized unit activity.

Worked evenings and weekends for home care agency serving Boston and MetroWest communities. Assessed patients in their homes and implemented plans and interventions involving IV therapy, enteral nutrition, and wound care.

Promoted long term acute care (LTAC) programs to case managers and physicians. Performed chart review and assessment, ensuring safe transition of patients from acute care setting to long term acute care facilities. Verified insurance coverage and obtained authorizations.

Developed marketing strategies to attract patients to subacute and long term care facility. Evaluated patients based on Medicare and insurance criteria and coordinated discharge of patients.

Registered Nurse on Trauma/Orthopedics Floor