Kristi

Compassionate social worker with experience in hospice, nursing home, geriatric care, care coordinator, case management (LTACH) and mental health settings. Skilled in conducting needs assessments, developing individualized care plans, and advocating for patient rights and equitable access to care. Collaborates effectively with interdisciplinary teams to improve care coordination, patient satisfaction, and quality of life.

Provides community, state, and federal resources, including Prescription Assistance Programs (PAPs) and Florida Medicaid application support.

Experience with Medicaid, Medicare, and Medicare Advantage programs.

Hospice Social Worker at Community Hospice and Palliative Care (2022-04 – 2026-02)

• Conducted thorough assessments of patient needs, goals, and preferences for end-of-life care.
• Developed individualized care plans addressing the emotional and social needs of patients.
• Delivered supportive counseling for families facing terminal illness and end-of-life challenges.
• Advised caregivers on coping strategies for the physical and emotional demands of terminal illness.
• Provided crisis intervention during acute distress or changes in patient condition.
• Educated families on community resources and services, reducing caregiver burden and services to enhance coping strategies. Assisted patient and families with Medicaid applications and advocated services through collaboration with their insurance plans (Medicaid, Medicare, Medicare Advantage plans)
• Attended interdisciplinary team meetings to collaborate, advocate, and enhance patient care planning decisions.
• Managed caseloads by prioritizing tasks based on urgency to ensure timely support.
• Attended CEU seminars related to clinical hospice social work practices.

Long Term Care Coordinator (Temp) at Staywell/Wellcare (2021-08 – 2022-03)

• Coordinated access to essential medical and long-term care services, enhancing orientation care plan development.
• Conducted assessments with members, caregivers, or providers to evaluate client needs and service requirements.
• Authorized and coordinated referrals for benefits and services.
• Ensured uninterrupted provider service delivery while identifying gaps in care plans.
• Facilitated integration of informal or voluntary services into member care plans, improving overall care coordination.
• Monitored service delivery through telephonic follow-ups, ensuring timely support for members and caregivers.
• Collaborated with discharge planners and physicians to ensure effective discharge and care plan coordination.
• Assisted members in filing complaints and resolving appeals related to services.

Hospice Social Worker at Haven Hospice (2018-03 – 2021-05)

• Counseled families facing terminal illness, offering essential emotional support and guidance.
• Conducted comprehensive assessments for patients in hospice care to identify needs.
• Developed individualized care plans addressing emotional and social requirements.
• Collaborated with interdisciplinary teams to ensure holistic patient care approaches.
• Educate families on community resources and support services to enhance coping strategies. Assisted patient and families with Medicaid applications and advocated for services through collaboration with their insurance plans (Medicaid, Medicare, Medicare Advantage plans, etc)
• Documented patient progress and interventions in electronic medical records.
• Advocated for patients' rights within healthcare systems, ensuring preferences are respected.
• Facilitated access to resources that reduced caregiver stress and improved family dynamics.

HCM-SS Social Services Care Manager at Humana at Home (2011-05 – 2018-01)

The Humana Cares Manager-Social Services (HCM-SS) proactively and telephonically assesses eligible Humana members and engage participation in Humana Cares Complex Care and Chronic Conditions Management program.

• Complete psychological, cognitive, emotional, physical, social, economic and environmental assessments, to provide appropriate and timely interventions to ensure provision for maximum care.
• Guide members and their families towards and facilitate interaction with resources (including Prescription Assistance Programs (PAP's) appropriate for their care and well-being. Advocated for patients' rights and preferences in care decisions.
• Supported members and families by coordinating healthcare and community resources, advocating patient rights, and facilitating referrals for medical, housing, mobility, and financial assistance.
• Used motivational interviewing to evaluate and educate members on support, motivate change, and to achieve and/or maintain optimal wellness.
• Actively assist with questions and conference calls to advocate and educate members on benefits.
• Accountability: Meet established expectations and take responsibility for achieving results; encourage others to do the same; meets metrics within service level standards and ensured that all documentation is completed accurately according to state regulations.

Social Work Supervisor/Social Worker at HPH Hospice (2003-01 – 2011-02)

• Supervised social work team for nursing homes and assisted living facilities over three years.
• Conducted psychosocial assessments to develop tailored care plans for patients.
• Collaborated with interdisciplinary teams to coordinate comprehensive patient services.
• Managed crisis intervention and addressed emergency situations promptly.
• Monitored staff performance and conducted evaluations to promote professional growth and enhance service delivery.
• Supported MSW interns with leadership training and skill development to prepare them for clinical roles.
• Advocated for patient rights, preferences, and access to community resources. Assisted patient and families with Medicaid applications and advocated for services through collaboration with their insurance plans (Medicaid, Medicare, Medicare Advantage plans, etc)
• Implemented marketing strategies to improve quality assurance and foster family engagement.

Masters of Social Work in Social Work – University of Central FL

Bachelors of Social Work in Social Work – University of South FL