I proactively manage care including, but not limited to care management planning, referral management, post-discharge planning, and coordinating transitional and community based care. With a focus on delivering comprehensive patient-centered care across the health care continuum. Close collaboration with provider practices to deliver care coordination, chronic care management, coaching, consultation and intervention with a particular focus on patients with complex health care needs.
Analysis and dissemination of patient health goals/outcomes.
Currently completing a Masters in Nursing with a focus on Informatics.