Practiced Care Plan Coordinator dedicated to timely and accurate completion of individual assessments, supporting development of comprehensive care plans. Collaborates with interdisciplinary team in monitoring progress and adjusting plans to achieve target results. Observes individualized care, recommending opportunities for improvements.
Overview
18
18
years of professional experience
Work History
Post Transition Care Coordinator
Trillium Health Resources
01.2024 - Current
Responsible for providing care coordination (treatment planning, assessment, monitoring, educating/linking) to individuals identified in the Transitions to Community Living Initiative Special Populations (TCLI) by targeting those chronic, unresolved, or complex physical, behavioral health, and social determinant needs
Responsible for providing care planning as well as discharge and transition planning from Adult Care Homes, in-patient units and detention centers with evidence-based practices/standards for whole person care
Works collaboratively with licensed clinicians, registered nurses, mental health care providers and peer supports to ensure successful discharge/transition planning and post transition monitoring
Provides care coordination/care management to 55 assigned TCL individuals who have identified needs with behavioral health, physical health co-occurring, co-morbid or multi-morbid conditions
Assesses member's needs who have transitioned to supportive housing to determine if additional supports are needed for continued independent living
Completes Care Management Comprehensive Assessments and other assessments
Ensures timely and accurate documentation of all transition planning/post transition planning and monitoring/coordination efforts in company software and multiple State database systems.
Social Worker III - Adult Services
Duplin County Department of Social Services
11.2019 - 01.2024
Adult Services Social Worker with 18 years of experience coordinating care/services for individuals living with disabilities in private and long-term care settings
Case Management experience in the following program areas: Adult Guardianship Services, Representative Payee Services, Special Assistance In-Home Services, Adult Protective Services Evaluation and Planning/Mobilization Services, and Adult Home Specialist Services
Extensive experience with face-to-face home visits, telephone contacts, person-centered service plans & goal setting, quarterly review and annual reassessment for services, economic worksheets and budgeting, services referral and follow-up, Estates and Special Proceedings involving the Clerk of Court, routine monitoring and compliant investigation for Assisted Living Facilities and Family Care Homes
Knowledge of NC DHHS programs, Medicaid and Medicare benefits, application processes and documentation, as well as requirements for LTC/SNF placement
Knowledge of NC FACTS & NC TRACKS systems, Social Security Administration benefits/payments including SSDI/RSDI/SSI, Food Nutrition Services benefits and Crisis programs
Extensive knowledge of the NC DHHS Division of Aging & Adult Services program manuals and forms, DHSR Rules & Regulations, Residents Rights and Long-term Care Ombudsman services
Customer service experience; friendly & personable, efficient, organized and experienced with fast-paced working environment.
Social Worker III - Adult Services
Wayne County Department of Social Services
03.2017 - 11.2019
Adult Services Social Worker with 18 years of experience coordinating care/services for individuals living with disabilities in private and long-term care settings
Case Management experience in the following program areas: Adult Guardianship Services, Representative Payee Services, Special Assistance In-Home Services, Adult Protective Services Evaluation and Planning/Mobilization Services, and Adult Home Specialist Services
Extensive experience with face-to-face home visits, telephone contacts, person-centered service plans & goal setting, quarterly review and annual reassessment for services, economic worksheets and budgeting, services referral and follow-up, Estates and Special Proceedings involving the Clerk of Court, routine monitoring and compliant investigation for Assisted Living Facilities and Family Care Homes
Knowledge of NC DHHS programs, Medicaid and Medicare benefits, application processes and documentation, as well as requirements for LTC/SNF placement
Knowledge of NC FACTS & NC TRACKS systems, Social Security Administration benefits/payments including SSDI/RSDI/SSI, Food Nutrition Services benefits and Crisis programs
Extensive knowledge of the NC DHHS Division of Aging & Adult Services program manuals and forms, DHSR Rules & Regulations, Residents Rights and Long-term Care Ombudsman services
Customer service experience; friendly & personable, efficient, organized and experienced with fast-paced working environment.
Social Worker III - Adult Services
Duplin County Department of Social Services
07.2006 - 03.2017
Adult Services Social Worker with 18 years of experience coordinating care/services for individuals living with disabilities in private and long-term care settings
Case Management experience in the following program areas: Adult Guardianship Services, Representative Payee Services, Special Assistance In-Home Services, Adult Protective Services Evaluation and Planning/Mobilization Services, and Adult Home Specialist Services
Extensive experience with face-to-face home visits, telephone contacts, person-centered service plans & goal setting, quarterly review and annual reassessment for services, economic worksheets and budgeting, services referral and follow-up, Estates and Special Proceedings involving the Clerk of Court, routine monitoring and compliant investigation for Assisted Living Facilities and Family Care Homes
Knowledge of NC DHHS programs, Medicaid and Medicare benefits, application processes and documentation, as well as requirements for LTC/SNF placement
Knowledge of NC FACTS & NC TRACKS systems, Social Security Administration benefits/payments including SSDI/RSDI/SSI, Food Nutrition Services benefits and Crisis programs
Extensive knowledge of the NC DHHS Division of Aging & Adult Services program manuals and forms, DHSR Rules & Regulations, Residents Rights and Long-term Care Ombudsman services
Customer service experience; friendly & personable, efficient, organized and experienced with fast-paced working environment.
Education
Bachelor of Science - Psychology
Mount Olive College
Mount Olive, NC
05.2006
Skills
Case Management
Developmental Disabilities Experience
Crisis Intervention
Behavioral Health
Care Coordination
Social Work
Intake/Assessment/Referral Experience
Autism Experience
Motivational Interviewing
ADD/ADHD/IDD Experience
Behavioral Health/Therapy
Timeline
Post Transition Care Coordinator
Trillium Health Resources
01.2024 - Current
Social Worker III - Adult Services
Duplin County Department of Social Services
11.2019 - 01.2024
Social Worker III - Adult Services
Wayne County Department of Social Services
03.2017 - 11.2019
Social Worker III - Adult Services
Duplin County Department of Social Services
07.2006 - 03.2017
Bachelor of Science - Psychology
Mount Olive College
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