Case Manager Care Management
Resume:
Patricia Hughes
Bayonne, NJ *****
Experience
Somos Community Care
Case Manager
Remote position
*/**** – Present
• Case Manager provides acute, short term disease management within the Medicaid population (1 insurance contract).
• Pediatric Asthma Disease Management, Adult Diabetes CM, Complex Care CM, Catastrophic Care CM, Transition Care Management, Identified SDOH which include but are not limited to Housing Insecurity: including homelessness, shelter residents, family shelter, unsafe housing, evictions, food insecurity.
• Work closely with SW and community outreach workers to assist with accessing community resources: SNAP; housing court, financial resources, healthy living/asthma resources
• Beginning 12/2024, two additional insurance providers for Long Term Services and Support (LTSS).
• Transition from the previous vendor to Somos has included established LTSS patients and newly enrolled LTSS patients.
• The case managers are responsible for assessments, medication reconciliations, coordination of services, authorization requests, interdisciplinary care planning, provider communication, and any other associated tasks.
USFHP
Lead Case Manager
7/2019- 8/2023
• Responsible for assisting the team in developing strategies that will be used to reach individual and organizational goals.
• The Lead Case Manager will coordinate and assist with the identification of the members who could benefit from case management.
• Provide education and training to the team members related to plan and regulatory standards. Communicate the goals and expectations for Medical Management Team and encourage feedback.
• Monitor the case manager’s interactions with the members to ensure that the training and education provided is accurate and appropriately applied.
• Provide a supportive environment and encourage collaboration and assistance with any complex issues.
• The Lead Case Manager is responsible for evaluation of each member of the Medical Management Team and providing the ongoing education, coaching, mentoring, and or counseling that may be needed.
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• Responsible for the day-to-day operations of the Medical Management team and any other assorted duties.
• Maintain a positive working relationship with the other teams at USFHP. Report to the Director of Medical Management
USFHP
Clinical management Specialist (Case Manager)
6/2016- 7/2019
• Provide comprehensive case management interventions to a mixed panel of members. Identify those members who are identified as high risk and or high utilizers.
• Expedite access to the appropriate level of care.
• Assess member’s heath care needs and develop an individualized plan of care for that member. Identify specific objectives, goals and interventions.
• Provide education related to disease management and community resources.
• Assist and facilitate the member’s transition form one level of care to another.
• Provide emotional support to the member and the family as needed.
• Identify members that may need input from the Medical Director. Refer those members with quality concerns or inappropriate use of services to the QA director.
• Utilize critical thinking, judgement, independent analysis, clinical guidelines, and benefits to ensure that the member receives the highest quality of care.
• Assess the medical and psycho-social needs of the members and refer to the appropriate services as Tricare and DOD policies.
• The case manager is responsible for Issues that may require case management intervention. Mt Sinai/ Beth Israel
Care Manager
9/2013-4/2016
• This was a grant funded position through CMS and Health First to ensure a smooth transition from in- patient to outpatient care.
• The care manager was responsible to identify those patients at high risk for readmission related to the diagnosis or lack of community support or resources.
• The care manager collaborated with the inpatient medical team and the outpatient case managers at MS/BI Clinics.
• The care manager was required to follow grant specifications which included daily chart reviews, identification of those high-risk members and scheduled follow-up appointments prior to discharge. 3
Bayonne Medical Center
Case Manager
9/2010-9/2013
• The case manager reviewed clinical charts based on Interqual for appropriate admissions, continued stay and discharge screening.
• Worked closely with the interdisciplinary team, patient and the family to develop a safe and individualized discharge plan.
• The case manager ensured that the services provided in the acute care setting were completed in a timely manner and met the criteria as established by Medicare, Medicaid and all Commercial and Private Insurances.
• Arranged post hospital care which included both skilled and unskilled home care referrals, rehab placement and long-term care placement as appropriate. Promise Care NJ LLC
Lead Team Manager
8/2008-6/2010
• The lead team manager worked closely with the Medical Director and the CEO to ensure that the optimal level of care was provided to each patient as per Medicare guidelines.
• Assisted with the review and adjustment of policies as needed.
• Provided direct supervision of and ongoing education to the clinical managers and the visiting staff.
• Provided one-to-one counseling and support to managers and staff as needed.
• Worked with the PI department to evaluate the effectiveness of care and identify those areas that required improvement.
• Assisted with the development of corrective action plans. Education
St Vincent Hospital School of Nursing
New York NY
Registered Nurse Diploma 1980
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