Social Worker - Medicare & Care Coordination Expert

CAROLINE ALLEN, MSSA LMSW 480-***-**** - ************@******.***

PROFESSIONAL EXPERIENCE

Medical Social Worker

Compassionate and dedicated care supporting diverse populations within Medicare framework, seasoned skill at navigating complex healthcare systems, coordinating care and advocating for the physical, emotional, and financial needs of members. Adept at collaborating with interdisciplinary teams to ensure compliance with Medicare regulations while enhancing beneficiary’s outcomes. Proven ability to assess social determinants of health, develop care plans, and connect members to community resources. Committed to empowering clients through empathetic communication, crisis intervention, and resource navigation, delivering measurable improvements in client health and satisfaction.

Assessed and advocated for members’ social, emotional, and financial needs

Collaborated with ICT multidisciplinary teams, including physicians, nurses, and pharmacists to streamline care delivery and resolve coverage disputes

Educated members and families on insurance benefits, coverage limitations, and community resources to provide informed healthcare decisions

Developed and implemented discharge plans, coordinating post-treatment care

Analyzed insurance claims to identify trends in utilization, providing recommendations to improve care delivery and cost efficiency

Trained new staff and intern about insurance policies, medical terminology, and case management best practices to enhance team performance

Monitored regulatory changes and laws in healthcare and insurance policies, ensuring compliance in all activities, and provided group community presentations

Documented collaboration with external professionals and case progress in electronic health record systems, maintaining accuracy for audits Arizona Priority Care - Chandler, Arizona 5/2021-

CURRENT

Published in the internal professional spotlight for excellence of service Transitional Case Manager

Integrated member of the case management teams in six acute hospitals within the Honor Health system, working with patients and their families to ensure a smooth transition during admission and following discharge to post-acute settings to prevent unnecessary readmissions.

Identify medical and psychosocial determinants of health to remove barriers

Perform comprehensive initial and ongoing assessments, managing continuity of care for reduced length of stays

Advocate with interdisciplinary team to reduce avoidable delays in care

Maintain and manage daily caseloads and collaborate with other case managers and external partners on complex cases

Collaborating with internal/external providers, primary care physicians; specialists, and other healthcare professionals to ensure a smooth transition to outpatient care that is coordinated across the healthcare continuum

Member of the organization’s Preferred Provider Council which evaluates community partner metrics in key quality measures for initial and ongoing participation

Representative of company in quarterly collaborative meetings with leadership from community partners to maintain and build on performance measures

Volunteer member on the Social Committee

Licensed Master Social Worker

Provided social work services in hospital emergency department Honor Health – Innovation Care Partners - Scottsdale, Arizona 8/2019-5/2021 Maricopa Integrated Health System – Phoenix, Arizona 3/2019-6/2019

Completed assessments to assist in understanding needs and delivering resources and referrals

Provided crisis counseling and support to patients and their families

Managed consults related to behavioral health assessments, and substance abuse treatment and skilled nursing facility placements

Worked collaboratively with health care providers in formulating and implementing emergency department discharge plans

Lead Behavioral Health Professional

Lead behavioral health professionals in the operation of Southern Arizona’s telephonic Crisis Line

Manage risk factors and facilitating the supervision of more than 20 employees in providing crisis services

Coordinate care with RBHA health homes, first responders, and medical and psychiatric facilities

Maintain reports of acute matters; act as a middle liaison between employees and upper management

Answer crisis calls, triage, and provide care advice

Follow up to meet the needs of the population served

Experienced with Medicare, Medicaid and a wide range of insurance entities TRICARE Behavioral Care Advocate (Telecommute)

Provided compassionate clinical case management telephonically in the disease management and education program to support TRICARE members identified with depression, anxiety, and other medical conditions

Inspired curiosity to keep people engaged to participate in understanding how to make healthier choices

Resolved barriers addressed during assessments via effective care plans and resources to meet needs

Envolve Health People Care – Centene Corporation - Tempe, Arizona 1/2018-3/2019 United Healthcare Military & Veterans - Phoenix, Arizona 1/2015-1/2018

Achieved cost of savings by closing gaps in care and improved condition as reflected in the scores of objective assessments administered at the program start and after implementing expert interventions

Prevented ER visits by coordinating care with providers as well as interdisciplinary team, and collaborated with Utilization Management to decrease hospital delays

Empowered healthier lives with HEDIS initiatives, coaching people to stay in tune with managing their condition(s), including preventative care, and advocating for building better provider/patient partnerships

Mentored employees to assist them with a better understanding of work operations and meeting metrics

Volunteered on the Social Responsibility Committee to give back with bottled water, food, and toy drives

Case Manager / Crisis Therapist

Clinical services provided in the mental health and chemical dependency department, as well as crisis expertise throughout the hospital to assess and recommend services for children, adolescents, adults, and geriatrics.

Reduced risk/liability by consulting with physicians after completing crisis assessments to discuss diagnosis and to make recommendations for the next level of care

Managed multi-tasking and ongoing dialogue with interdisciplinary team, with patients and their support network, including SMI clinics, and updated insurance companies as needed with concurrent reviews

Mastered identifying delays in care and tackled them to improve timely discharges Social Worker

Solution medical focused to improve quality of life for NICU infants, adolescents, adults, and geriatrics.

Banner Thunderbird Medical Center - Glendale, Arizona 1/2014- 12/2014

Arrowhead Hospital - Glendale, Arizona 3/2013-

11/2013

Contributed to the safety of patients as necessary with CPS and APS reports and assisting with DME

Reviewed medical charts to ensure all requested data was present for document images electronically to be forwarded to an authorized entity, coordinating care with a SNF, rehab and hospice facilities

Helped patients and their loved ones cope with adjusting to medical conditions, disabilities, grief and loss

Intake Social Worker / Utilization Management Coordinator / Behavioral Interventionist

This start-up mental health and rehab agency offered experience in office and field-based environments to assess bio-psych-social needs with adults and geriatric patients, and obtaining insurance authorization for treatment by completing pre-certifications, initial admission chart review, and ongoing inpatient utilization reviews.

Innovative ability to obtain crisis details from suicidal TRICARE soldier serving our Country, to the SMI population suffering with serious mental illness, to the people struggling with drug or alcohol dependency

Successful Medicare accreditation with audited observations of my direct work ethics

Established earned trust and rapport with insurance reviewers via chart updates for service authorizations

Expert witness testifying in response to my notarized submitted petitions for court ordered treatment on behalf of patients at imminent risk for danger to self or others who declined help

Crisis Counselor

Responded to field-based calls for crisis psycho-social assessments requested by medical providers in acute medical settings to evaluate children, adolescents, adults and geriatrics and coordinate next steps of care.

Valley Hospital - Phoenix, Arizona 3/2011-6/2013

Compass Mental Health - Phoenix, Arizona 4/2010-3/2011

Developed great connections with community medical staff who asked for me by name for consults

Established better outcome decision making by thorough chart reviews, diagnostic and medication history, lab results, and SMI status, presenting opportunities to prepare for initial encounters

Assessed patients to determine current disposition which was staffed with both their physician and nurse

Networked with people in the profession, learned expectations, and promptly moved patients out of hospitals into specialized inpatient facilities or in the care of someone helping with outpatient services

Drafted petitions for court ordered treatment and gave expert testimonies to preserve patient safety

Managed care experience with several insurance entities including Medicaid, Medicare, and TRICARE

Clinical Liaison

Provided clinical oversight for Case Mangers and forged a partnership with SMI members and their providers.

Led Case Managers with clinical oversight

Managed a small caseload with members who had frequent hospital utilization

Advocated for efficient and cost-effective methods, following up with members in their homes after discharges to offer motivational coaching for treatment compliance, resulting in less hospitalizations

Director / Coordinator

Managed state / federal public health grants and brought a 24-hour program into regulatory compliance.

Magellan Health Services / Value Options - Phoenix, Arizona 6/2007-3/2008 Hudson County Rape Crisis Center - Jersey City, New Jersey 11/2001- 5/2003

Supervised, trained, and retained 4 employees, 2 student interns, and over 10 volunteers, leading by example answering hotline calls, and accompanying survivors through medical and legal proceedings

Advocated to respect the rights of sexual assault survivors

Empowered males and females via individual, family, and group counseling

Delivered education on services available with public speaking engagements with up to 100 attendees

Created public awareness of sexual assault by accepting the invitation to talk on live radio with Rick Sanchez from MSNBC, and responded to people who called in with questions

Interviewed with Hoy Newspaper, resulting in a published article about assistance available

Increased funding 50%

Manager

Supervised local property managers.

Contracted with local services providers for home improvement and maintenance services

Traveled to locations as necessary to maintain order

Successfully organized the marketing and the operation of residential real estate investments; overcame economic downturn to keep investments profitable and organized the sale of properties

Therapist

Provided group and individual therapy to families and children

Expertise in trauma, major depression, anxiety, attention deficit and disruptive disorders

Residential Settings – Erie, PA 8/2001-

11/2009

Beech Brook Treatment Center for Children – Cleveland, OH 6/1999 – 7/2001

Clinical attention related to abuse and neglect, learning and medical disabilities, autism, and relational difficulties

Led partial hospitalization groups, individual counseling sessions and play therapy EDUCATION, LICENSURE, & CAREER AFFILIATION

Master of Science in Social Administration, Case Western Reserve University Bachelors, Psychology, Cum Laude, Russell Sage College Licensure: Arizona Licensed Master Social Worker

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