Geriatric Care Manager

• Jan 2023 - Present

Social Support Coordinator - Client: PA Department of Health

• Aug 2020 - Jun 2021

• Defined the Social Support Coordinator (SSC) role for the Pennsylvania Department of Health COVID-19 Contact Tracing and Case Investigation program as a member of the project leadership team. • Designed and implemented processes and protocols for the SSC, Inbound Calls, Contact Tracing, Sara Alert Hunt Group, Case Investigation and Case Investigation Quest Teams. • Developed and continuously improved a comprehensive statewide resource guide of social services and mental health support, and addiction programs. • Provided education on isolation and quarantine guidelines to PA residents who had been exposed to or were positive for COVID-19, while advocating for residents by providing up-to-date resources and support. • Collaborated with state organizations, community-based organizations, and support agencies to address community issues including, but not limited to housing, food insecurity, mental illness, medical testing, healthcare, and other needs. • Provided continuous and consistent coaching and support for around 100 employees, which include supervisors and contact tracer agents in their navigation of referrals for social support. • Facilitated soft skills training for supervisors, contract tracers, and all team members regarding effective communication, empathy, active listening, navigating difficult interactions during a crisis, as well as self-care, and other personal support. Show less

Social Services Specialist II

• Nov 2018 - May 2020

• Assured timely entries in the patients charts to include but are not limited to: Social History Evaluation & Assessment, a care plan to address strengths, problems, needs, and interventions, substantiation of psychosocial interventions, progress toward, and/or completion of goals, and transfers. • Served as active contributor in designated center meetings at request of Social Services Director (Utilization Management, Care Planning, etc.) • Worked with patients and families to provide support and information for taking a more proactive role in self advocacy to improve the quality of life/care for individual patients and those who live and work with the nursing facility and community at large. • Worked in tandem with community-based providers i.e., behavioral health, hospice providers, etc. and coordinates the clinical application of services to assure continuity of care. • Identified patient discharge goals on admission and documented initial discharge plan. Completed referrals as needed for post discharge care to appropriate agencies and suppliers. Initiated and participated in completion of Discharge Transition Plan & Discharge Packet materials while orienting the patient/resident and family around the processes. Show less

MSW Care Coordinator

• Dec 2012 - Nov 2018

• Completed cross continuum care coordination, inclusive of psychosocial assessments and interventions to evaluate discharge planning needs for patients and their families. • Collaborated with physicians, peers, community colleagues, and others to orchestrate care across the health care continuum, to identify opportunities to continually improve patient care and services, to improve population health, and to achieve collaborative practices that exemplify commitment to patient centered care and community engagement.• Communicated with multi-disciplinary treatment team members, patients, families, and outside agencies to provide the safest discharge plan fostering positive outcomes. • Utilized all software programs within Main Line Health to maintain patient medical records and complete appropriate referrals for discharge planning needs. • Supervised MSW students and assisted with orientation/training of new team members.• Member of the Stroke Committee, Nurse to Nurse Handoff Committee for Skilled Nursing Facilities, Care Coordination Services Development Team; Schwartz Rounds Panelist• Epic Super User and Elsevier CPM Champion Show less

Medical Social Worker

• Jul 2011 - Dec 2012

Development Coordinator

• Aug 2009 - Jan 2011

• Crafted grant proposals, reports and communications materials for institutional funders, foundation, and corporate supporters. • Assisted in strategizing and researching new funding prospects. • Planned and carried out a fund-raising campaign (including proposals, annual appeal, special events, etc.) that reached all revenue projections. • Identified and followed clear plan to achieve fundraising goals, tracking with regular reports, adjusting as needed, and maintained fundraising software records • Collaborated with program staff on project design and budgets and assisted in the development of the annual budget to be confident that the revenue projections are ambitious but attainable. • Stayed abreast of current trends and resource availability within the health and human service field and matched those resources with the organization and its programs. Show less

Case Manager

• Jun 2008 - Jul 2009

• Coordinated management of care for a specified patient population (LTAC-Long Term Acute Care Hospital); followed patients throughout the continuum of care and ensured optimum utilization of resources, service delivery and compliance with external review agencies. • Provided ongoing support and expertise through comprehensive psychosocial assessment, care planning, plan implementation and overall evaluation of individual patient needs. • Enhanced quality of patient management and satisfaction, to promote continuity of care and cost effectiveness through the integration of functions of case management, utilization review, and management of discharge planning. • Utilized InterQual Criteria and completed insurance reviews. • Facilitated weekly patient care conferences with physicians and multidisciplinary treatment team to collaborate in the development and execution of the plan of care and achievement of goals. Facilitated family care conferences to review patient progression of care and provided family education on post hospital needs. • Attended daily Flash meetings with administrative personnel, including CEO, CCO and Director of Quality/Risk Management. • Completed CDI Training program and received certification. Show less

Lead Social Worker

• Aug 2004 - May 2008

• Arranged and coordinated a broad spectrum of discharge planning services for ICU and cardiac units. Able to cover entire hospital population (i.e., orthopedic, hemodialysis, maternal/child health, etc.). • Consulted with interdisciplinary treatment team members, patient/family to determine post hospital needs. Provided information on resources available and assisted with all necessary referrals. Provided support/encouragement as needed through-out process. • As Lead Social Worker, responsible for coordination and facilitation of quarterly social work meetings for four hospital locations. • Provided leadership, guidance, and support to all system-wide social workers and coordinated social work continuing education programs. • Member of Critical Care Committee, Bio-Ethics Committee, Memorial Mentors-focus on patient satisfaction, and Tri-County Regional Ethics Committee. • Trained as Peer Coach and Star Coach (Six Sigma/CAP/Workout sessions). Show less

Medical Social Worker

• Mar 2003 - Jul 2004

• Assessed needs of clinical population ranging from newborn up through geriatric with special considerations to age, diagnosis, and patient's ability to cope with illness. • Documented progress in the medical record, coordinated community supports, and participated with multidisciplinary team (physician aligned). • Assisted patients/families with the establishment of discharge goals and the development of safe and appropriate discharge plans. • Assessed needs of clinical population ranging from newborn up through geriatric with special considerations to age, diagnosis, and patient's ability to cope with illness. • Documented progress in the medical record, coordinated community supports, and participated with multidisciplinary team (physician aligned). • Assisted patients/families with the establishment of discharge goals and the development of safe and appropriate discharge plans.

Assistant Care Manager

• Mar 2002 - Mar 2003

• Facilitated admissions to both inpatient and outpatient mental health and chemical dependency programs. • Actively case managed by concurrently reviewing all levels of treatment from assessment through aftercare, to resolution of treatment. • Consulted with MD supervisors to address appropriate treatment planning. • Participated in the competency committee to re-create care management position descriptions. • Assisted in training process for new employees. • Facilitated admissions to both inpatient and outpatient mental health and chemical dependency programs. • Actively case managed by concurrently reviewing all levels of treatment from assessment through aftercare, to resolution of treatment. • Consulted with MD supervisors to address appropriate treatment planning. • Participated in the competency committee to re-create care management position descriptions. • Assisted in training process for new employees.

Child/Adolescent Psychiatric Unit/CAPU Clinician

• Jul 2000 - Mar 2002

• Facilitated individual, family, and group therapy for children ages 4 to 18 years old. • Assessed patient/family treatment and discharge needs. • Communicated with community agencies to provide case management and discharge planning to patients and their families (i.e., Division of Youth and Family Services and Youth Case Managers). • Collaborated with treatment team daily to discuss treatment plans and discharge needs. • Performed insurance reviews. Completed intake referrals. • Received Certificate of Achievement Award in recognition of outstanding performance and commitment to excellence. Show less