Assisted and provided support to residents and family members throughout the duration of their stay.

• Case Manager discharge planner for Medicare & HMO cases, and Long-Term Care residents.
• Build and Maintained effective communication with Medica, Preferred, Careplus HMO case managers, resident's and family members, Home Health Agencies, and vendors.
• Constant communication with all Interdisciplinary team members to ensure correct and updated resident's status.
• Met with resident's and/or family members to assess current status, obtain advance directives and discharge plan details.
• Active role in maintaining communication with all departments to ensure developing, implementing, and evaluating care plans.
• Promoted healthy behaviors and lifestyle changes.
• Provided education and tools to promote and improve healthier outcomes.
• Obtained, clarified and fulfilled Doctor's orders for discharge.
• Notified responsible party of discharge date and generated the NOMNC letters for them to sign in a timely manner.
• Assisted in appeals process by properly submitting all pertinent documentation to Kepro.
• Arranged all necessary Durable Medical Equipment, Home Health Services and Transportation for a safe and successful discharge.
• Attended Case Management Utilization Review meetings on a weekly basis.
• Reviewed all incoming Preadmission Screening and Resident Review (PASRR).
• Reviewed charts & EMR, entered data and documented in the system on a regular basis.
• Followed HIPPA rules and regulations at all times.
• Responsible in obtaining and submitting proper documentation to DCF and CARES for Medicaid pending applications, recertification and annual reviews for the facility.

Continually monitored and managed the care given to each individual resident.

• Planned, organized, developed, and coordinated care plans.
• Active role in maintaining communication with all departments to ensure developing, implementing, and evaluating care plans for residents.
• Scheduled and held Care Plan meetings. Ensured residents and/or responsible parties attended care plan meetings and documented all care conference summaries in a timely manner.
• Communicated effectively with residents and their families to ensure they were receiving excellent care and that their needs were being met throughout their stay.
• Proficient and knowledgeable with different requirements for case mix, managed care, skilled services, and reimbursement.
• Knowledgeable on documentation guidelines for skilled resident in conjunction with PDPM documentation guidelines.
• Maintained MDS assessment calendar, coordinated the completion of all MDS assessments, and ensured timely completion of assessments, and care plans.
• Checked and resolved MDS errors via utilization of TSI scrubber.
• Attended and participated in weekly Utilization Review meetings.
• Knowledgeable in PDPM documentation requirements, guidelines, clinical standards, regulations & reimbursement.
• Continuously reviewed charts and electronic medical records.

Utilized the nursing process to safely, therapeutically and efficiently care for resident’s during the duration of their stay. • Actively assessed, planned, implemented and delivered patient care. • Implemented physicians’ orders by administering medications and performing treatments. • Entered physician orders and documented in Electronic Medical Records. • Monitored patient vital signs. Documented and notified physician of any changes. • Prioritized patient safety. Promoted health and well-being. • Advocated for my patient and preserved their dignity. • Educated patient and family members to help them make informed decision on their care. • Checked cart daily for any expired medications. • Stocked my cart with supplies and maintained all equipment clean. • Followed HIPPA rules and regulations at all times.

Received physician orders to be entered into EMR and reviewed charts to ensure compliance.

• Obtained paper orders to enter into the POS medical record.
• Maintained close communications with Nurses, Nurse Manager and DON.
• Reviewed the POS and compared it with the EMR to ensure all orders matched.
• Assisted in organizing folders for flu, pneumococcal vaccinations and pharmacy recommendations for the long-term floor.
• Generated reports with my system findings for each resident.
• Entered clarification orders immediately.
• Submitted & followed up with IDT members in regard to orders.
• Followed HIPPA rules and regulations at all times.
• Continuously reviewed charts and electronic medical records.

Obtained accurate and complete information from patients, families, and, if applicable, third parties to determine financial eligibility and submit subsequent applications to governmental assistance programs.

• Interviewed clients to collect all pertinent documentation needed to review for eligibility.
• Obtained signatures for all consent forms from all parties involved.
• Submitted applications and all documents to the Florida Department of Children (DCF).
• Collected all clinical documentation from current chart and electronic medical record.
• Reviewed that all clinicals were correct and completed before submitting for a Level of Care with the Department of Elder Affairs.
• Continuously followed up until a Level of Care was received and Notice of Care Action (NOCA) was obtained.
• Determined appropriate actions needed to resolve or correct resident status if ineligible.
• Notified families of their loved ones upcoming recertification or annual renewals.
• Collected updated information on ongoing cases and reviewed for any change in assets.
• Reviewed and updated the Next Review Date (NRD) Log on a daily basis.
• Notified Business Office, Administration, Utilization Review, and Social Services of case screening determinations and outcomes via verbal and written communication.