Seasoned nursing professional offering proven clinical knowledge, natural interpersonal strengths and technical abilities. Knowledgeable about CPRS,Vista charting, medication administration and interdisciplinary collaboration focused on optimizing patient care and support. Quality-focused and efficiency-driven leader. Dedicated and professional with history of meeting company goals utilizing consistent and organized practices. Skilled in working under pressure and adapting to new situations and challenges to best enhance the organizational brand.
• Work closely with interdisciplinary care team and technology to identify high-risk, complex patient cases; manage care, including referral management, care planning, post-discharge planning and coordinating community-based and transitional care
• Conduct individualized clinical evaluations of patients, their health needs and concerns; develop personalized action plans, provide education and issue referrals for care management programs; monitor patients' progress in meeting established goals and modify care plans accordingly
• Use evidence-based, comprehensive care plans to manage patients
• Develop a cohesive and strong team-oriented relationship with physicians, nurses and other healthcare professionals; evaluate and report on patient health outcomes and work in partnership with interdisciplinary healthcare team to facilitate the best in patient care
• Direct discharge planning process in support of treatment adherence and medication compliance; assist with transitions for patients discharged from an in-patient hospitalto a skilled nursing facility.
Developed and modified patient care plans and assisted interdisciplinary team in identifying client needs and goals to determine priorities of care.
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