Goal-oriented bilingual English/Spanish Registered Professional Nurse with over 10 years of case management
experience seeking position within an organization that can offer complex and challenging assignments
allowing for professional growth and development.
Case Management / Care Coordination Experience
Provided direct services to individuals living with chronic medical conditions, such as assessment, planning, implementing, referrals and ongoing evaluation. Additional services include, but not limited to health promotion, medication adherence, treatment education and daily observed therapy.
Completed comprehensive assessments to patients in a clinical based setting providing direct referrals for urgent/immediate needs identified and supportive case management as needed.
Referred patients to case management programs based on their individual needs and preferences.
Supervised and trained staff on program service deliveries based on NYCDOH curriculum. Monitored training activities for all staff. Coordinated departmental and interdepartmental trainings and conferences.
Managed and coordinated services for all clinic-based programs. Coordinated and directed departmental interdisciplinary case conferences.
Supervised and directed program staff; in addition to managing and monitoring daily program activities. Providing ongoing education and guidance to all program staff as needed.
Monitored and tracked epidemiological data, quality measures and compiled monthly report to contractual managers within NYSDOH/NYCDOH. Conducted monthly program analysis and development of all programmatic activities.
Developed linkage agreements with community-based organizations with the goal of continuity of care for all consumers.
Professional Experience
Healthfirst
Clinical Manager- Complete Care April 2020 - Present
Manage, support, and train a team of clinical staff including RNs and SWs
Conduct retrospective, concurrent and prospective audits for accuracy in clinical documentation, care planning, interventions and referrals
Plan, develop and implement trainings for staff related to performance improvement
Review processes in place and make recommendations for changes when appropriate given the needs of the members or plan
Identify solutions and develop strategies, meet with directors and management on a weekly basis
Provide weekly reporting, monitoring and feedback to the leadership team
Primary Care Manager- Dual SNP September 2017 - April 2020
Conducted assessments, developed patient centered care plans, performed defined interventions, and generated referrals to providers, community-based resources and appropriate social and medical services as needed.
Assessed member's physical, psychosocial and discharge planning needs through communication with appropriate hospital staff including attending practitioner, utilization review staff, discharge planners, social workers, and coordinate care accordingly.
Functioned as a clinical resource/educator for the multi-disciplinary health care team. Precepted onboarding case managers as needed. Participated in multiple special projects that enhanced the delivery of care to consumers.
Evaluated and pre-authorized requests for inpatient/outpatient, specialty care, home care, Durable Medical Equipment in accordance with departmental guidelines.
Documented all interventions and telephone encounters with providers, members, and vendors in the appropriate system in accordance with established documentation standards to ensure integrity of member services provided over the continuum of care and over time.
Coordinated discharge planning and transition of care for members returning to the community from in-patient hospital setting or nursing home. Ensured all anticipated needs were identified, requests made, case reviewed by the interdisciplinary team, and all specialty services in place prior to discharge home.
Glen Island Center for Nursing and Rehabilitation November 2018- Present
Nursing Supervisor
Monitor and supervise all nursing staff in facility during tour, provide in-service training, manage reporting of incidents, perform auditing of clinical duties/supplies/medications per unit.
Manage staffing assignments and direct care duties to unit nurses and nursing assistants.
Report changes in condition to medical provider, receive orders, update/endorse orders for all patients.
Initiate IV medications, fluid drips, conduct ongoing assessments of patients requiring higher level of monitoring.
Conduct admissions for short term skilled stay, complete discharges back to community, coordinate with interdepartmental staff.
Healthfirst July 2015 - September 2017
MLTC- Service Coordinator
Created authorizations for home care, skilled nursing, PT, OT, SLP, etc under the functions of the MLTC
Provided support to management and senior management in special projects for Utilization Management
Various locations- NYC February 2015- May 2017
Nursing Student
Assessed the immediate and continuing care needs of the patient.
Developed comprehensive plan of care which included physical needs, patient teaching, and discharge planning, as well as psychosocial/spiritual needs.
Provided direct patient care based on assessed needs and the medical regimen prescribed.
Observed, evaluated, documented, and communicated to relevant team members the patient's response to illness and/or therapeutic modalities.
Ensured timely reassessment of patient responses to treatment and reported significant changes that occurred in patient condition and/or diagnosis.
Wyckoff Heights Medical Center August 2009- March 2014
Senior Care Coordination Manager
Completed comprehensive biopsychosocial assessments, developed comprehensive care plan, delivered health promotion and orientation to Care Coordination program. Assigned cases to PNs. Monitored delivery of services on a weekly basis. Trained and supervised staff on a monthly basis. Assisted PM with special projects and completed monthly reporting to NYSDOH.
Managed, coordinated and supervised all programmatic activities, such as clinic-based education, interdisciplinary case conferences, training, track changes, appointments, home visits, treatment adherence.
Diaspora Community Services January 2007- April 2009
Case Manager-Supervisor
Assessed clients for comprehensive case management needs, developed comprehensive care plan, completed case conferences semi-annually with interdisciplinary team members to identify patients ongoing needs and ensure improved health outcomes.
Completed all required documentation pertaining to the client’s need as required by program protocol. Assessed and identified immediate needs, providing referrals when needed. Completed follow up with consumers on a weekly basis measuring outcomes on an on-going basis.
Conducted supervisory review of all cases assigned to team. Monitored clinical progress and retention in medical services. Monitored treatment plan and assessed adherence.
Trainings/ Skills
Case Management/ Care Coordination/ Transition
Treatment Adherence/
Retention in care/ DOT
Program Evaluation and Development
Risk Reduction/ Behavioral Counseling/ EBP
Substance Use/ Mental Health
Crisis Intervention/ Referral management
Outreach/Retention
Home Care/ Long Term Care/ Managed Care
Training/Education
Skilled care e.g. IV line insertion, wound care, palliative care
Community Resources
Medication Management and Education
Education
Chamberlain University Master of Science in Nursing- CNL Expected compl. 2021
Chamberlain University Bachelor of Science in Nursing 2020
ASA College Associate of Applied Sciences in Registered Nursing 2017
Boricua College Bachelor of Science in Human Services 2009
Certifications/ Licenses
BLS Certification 2020
Licensed Registered Professional Nurse NY/ FL/ Multistate 2017
Certification in Disability Management (CDMS) 2016
Certification in Case Management (CCM) 2015
Comprehensive Care Coordination Training / TOT 2011
Substance Use Counseling 350 Hr CASAC/ OASAS 2011
Stage-Based Risk Reduction Behavioral Counseling/ MI 2009
Recognitions
HealthFirst – Trailblazer Clinical Award Recognition 2018
Memberships
American Nurses Association
New York State Nurses Association
National Association of Hispanic Nurses
(Current NY Chapter Board Member 2020-22; Community Outreach Committee Liaison)
Case Management Society of America
Academy of Case Management
Association of Nurses in AIDS Care
American Association of Managed Care Nurses
American Holistic Nurses Association
References
References available upon request