Responsible for case management services with developing, monitoring, evaluating and revising the member's care plan to leet the member's needs and goals.
Responsible with case management of 200-250 members with low to high severity needs.
Performs telephonic or face-to-face clinical assessments for the identification, evaluation, coordination and management of member's needs, including physical and behavioral health, social services and long-term services.
Identifies members for high-risk complications and coordinates care in conjunction with the member and health care team.
Manages chronic illnesses, co-morbidities, and/or disabilities ensuring cost effective and efficient utilization of health benefits.
Gaps in care management.
Assist in problem solving with provider, claims and service issues.
Assist with SDOH issues that the member may have with referrals, resources with follow up.
SWAP RN for Home Health, Hospice and IV Team
Sentara System Wide Resource Pool
04.2022 - Current
RN with startup RN SWAP program for Home Health, Hospice and IV team. (System Wide Assignment Pool)
Travel within Sentara Enterprise locations for 2–12-week contracts for assigned department to assist with care of patient's in Home Health, Hospice and IV departments of Sentara Enterprises.
EPIC and CPR+ charting system
Hospice Registered Nurse
Sentara Home Care And Hospice
08.2017 - 04.2022
Case Manager for 3 years of 16-18 patients.
Developed and implemented individualized care plans for each hospice patient while following physician instructions.
Recognized and understood specific stages of the dying process, providing comfort-based care.
Care coordination with the interdisciplinary team for patients at IDT meetings and as needed for patient and families.
Follows physician orders for Intravenous therapy for pain management and Milrinone drip.
Care for LVAD patients in the home at end of life.
Night nurse on call from Mon- Thur from 5pm to 8am. Triaging calls for patient and family needs during the night for 130 patients.
Responded to incoming calls from the patient, family member, or caregiver for after-hours symptom management and gathered information to address inquiry or concern and ascertain the need to conduct an in-person nursing visit including pronouncement visits.
Preceptor to new nurses to hospice.
Home Health and Hospice Registered Nurse
Sentara Home Care And Hospice
02.2000 - 06.2005
Care for home health and hospice patients with variety of diagnoses.
Started as an evening nurse with home health and transferred to weekend nurse for hospice and home health.
Helped to achieve and maintain continuity of patient care by planning and exchanging information with other health professionals.
Developed and initiated individualized plan of care and assumed responsibility for ongoing development in partnership with patients, families, and caregivers with Admission visits.
Identified discharge planning needs as part of care plan development and implemented prior to discharge of patient with home health
Administered medications and treatment to patients and monitored responses while working with healthcare teams to adjust care plans.
Explained course of care and medication side effects to patients and caregivers in easy-to-understand terms.
Communicated with healthcare team members to plan, implement and enhance treatment strategies.
Administered different treatments and medications in line with physician orders and treatment plans.
Hospice responded to incoming calls from the patient, family member, or caregiver for after-hours symptom management and gathered information to address concern and ascertain the need to conduct in-person nursing visit including pronouncement visits.
Home Health Registered Nurse Case Manager
Olsten Kimberly Quality Care
09.1994 - 09.1999
Home Health Case Manager
Patient home visit to assess health conditions and provided nursing care.
Provided physical assessments, medication, and chronic disease management to home health patients.
Introduced changes to patient care plans based on regular evaluations.
Worked with the multidisciplinary team to carry out successful treatment plans for diverse acute and chronic conditions.
Preceptor for new nurses to the organization.
Determined and addresses individual home care needs by completing detailed assessments and reviewing documentation.
Supervisor visits with home health aides.
Blood draw samples to complete diagnostic and routine assessment tests.
Employee of the Month award.
Filled in for supervisor when she was on leave.
Medical Surgical Staff Registered Nurse
Sentara Norfolk General Hospital
09.1990 - 09.1994
Medical-Surgical Unit with patients who had a variety of diagnosis. The unit specialized in plastic surgery, urology and GYN Oncology.
Managed 7-10 patients simultaneously by providing bedside care, treatments, IV therapy, and wound care.
Educated family members and caregivers on patient care instructions for safe discharge to home.
Educated patients and families on medical-surgical procedures, therapeutic regimens, and pain management techniques.
Promoted patient and family comfort during challenging recoveries to enhance healing and eliminate non-compliance problems.
Preceptor to new nurses to the unit.
Charge Nurse as needed.
Worked days, evenings, nights and 12 hour shifts as needed.
Education
Bachelor Science in Nursing - Nursing
Capella University
Minneapolis, MN
09.2021
Registered Nurse - Diploma Registered Nurse
Sentara Norfolk General School of Nursing
Norfolk, VA
06.1990
Skills
Patient Care Assessment
Care Coordination
Compassionate and Caring
Diligence
Problem Solving
Accurate Documentation
Critical Thinking
Mentoring, precepting and teaching
Performs well as a team member and autonomously
Conscientious
Flexible
Timeline
Integrated Case Manager
Sentara Health Plan
01.2023 - Current
SWAP RN for Home Health, Hospice and IV Team
Sentara System Wide Resource Pool
04.2022 - Current
Hospice Registered Nurse
Sentara Home Care And Hospice
08.2017 - 04.2022
Home Health and Hospice Registered Nurse
Sentara Home Care And Hospice
02.2000 - 06.2005
Home Health Registered Nurse Case Manager
Olsten Kimberly Quality Care
09.1994 - 09.1999
Medical Surgical Staff Registered Nurse
Sentara Norfolk General Hospital
09.1990 - 09.1994
Bachelor Science in Nursing - Nursing
Capella University
Registered Nurse - Diploma Registered Nurse
Sentara Norfolk General School of Nursing
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