Cheryl Davis

Maintains the health and manages the care for veterans with a variety of medical problems including hypertension, diabetes, arthritis, cancer, congestive heart failure, and other chronic diseases. Assists the providers with answering secure messages, making referrals, renewing medications, patient intake, assessment and triage. Take histories and document conditions and concerns for veterans presenting to the clinic and via telephone. Coordinates care using health education, health coaching and health promotion.

Provide intensive case management and follow up to assigned mental health and substance abuse members as a consultant or care manager within specialty programs or regional care teams. Identify trends in the underutilization or over utilization of services. Analyze population-level data from electronic health records and other sources/platforms available. Collaborate with clinicians as a member of a care team and provide consultations as needed. Consulted with other behavioral health staff in designing appropriate plan of action for members with behavioral health needs.

Provides Care Management for At-Risk Children (CMARC for children ages 0-5 with developmental disabilities and/or chronic illnesses. Collaborates with Primary Care Provider and Clinic Coordinator to assist in compliance with the established plan of care through the acquisition and/or utilization of available community resources. Serves as an advocate for clients and their families who are enrolled in any maternal-child outreach programs. Performs outreach through home visits including client/family needs assessments. Develops plan of care and collaborates with other agencies and service providers maintaining good report to meet the needs of the client. Participates in Outreach/Agency audits and program reviews as necessary.

RN case manager for the Optum at Home DSNP program. Assess the health status of members with medicaid and medicare in their home or telephonically, virtually within the frequency described in the model of care. Establish goals and develop a plan of care to meet identified healthcare needs. Work collaboratively with a multidisciplinary team to engage resources and strategies to address medical, functional, and social barriers to care. Work closely with mental health clinicians to help bridge the gap between mental and physical health. Consult with the member's PCP, specialists, or other health care professionals as appropriate. Assess needs for community resources and make appropriate referrals for service. Facilitate the member's transition within and between health care settings. Complete bone density scans and check Hemoglobin A1C's as needed.

Assist the Director of Accreditation to facilitate compliance of all regulatory standards set forth by Joint Commission. Coordinate and conduct facilities assessments as part of continual readiness. Assist with post survey reports and submissions of items to The Joint Commission as required. Exhibit proficient understanding of compliance requirements /standards. Process sensitive, confidential and regulatory matters. Demonstrate self-directed work practices. Complete monthly chart audits. Attend and actively participate in meetings and trainings as required. Demonstrate knowledge and comply with all agency policies and procedures, as well as state and federal statutes and regulations related to specific program areas.

Assisted the team with monitoring routine and emergent medical care as specified by state regulations and service definitions. Periodically observed medication administration by staff to individuals in a residential/day program setting and self administration by individuals in order to ensure best practices are followed. Monitored documentation following medical appointments for individuals in residential services to ensure proper follow-up on recommendations. Reviewed monthly Medication Administration records,. Assisted with coordinating efforts between pharmacies, physicians, laboratories, etc. in order to ensure medical needs of individuals being supported were met. Prepared for annual compliance surveys and quarterly medication audits. Provided trainings to staff on protocols for special accommodations. Traveled to 15 different groups homes monthly to assess individuals with IDD/ SA/ Mental health disorders.

Traveled to patients homes to assess for personal care services. Supervised 85 in-home aides and provided educational in- services for aides as needed. Supervised and created care plans for over 100 clients, keeping all charts updated per state regulations. Communicated with clients, families, doctors, nurses and social workers as needed for maximum client care.

Traveled to client's home to assess for personal care services Develop plan of care. Supervised in-home aides and provided educational in-services as required. Kept all charts updated per state regulations . Communicated with clients, families, doctors, social workers and nurses to ensure quality care.

Nursing assessments, medication administration, completed referral process, phlebotomy, education, developed care plans. Communicated with doctors, counselors and social workers regarding patient care in alcohol and drug abuse treatment center.

Traveled to client's home to assess for personal care services. Performed supervisory visits every 60 days. Supervised in home aides. Taught yearly mandatory in services required by the state. Checked off CNA skills as needed. Documented in client and aides charts as needed to stay in compliance with state regulations.