Social Worker - DaVita Renal Care - Riverview, FL
(2025-07)
Clinical social worker in a renal care setting
- Assess new and ongoing hemodialysis in-center patients
- Utilize assessment tools to measure successful outcomes of patient's dialysis experience, treatment compliance, and ongoing mental health function
- Conduct social work counseling pathways by incorporating therapeutic interventions such as mindfulness; CBT, solution-focus; and strengths perspective
- Provide modality education
- Advance Care Planning & End of Life education
- Complete and submit transplant referrals for patients interested in moving forward with kidney transplant
- Maintain an ongoing relationships with transplant centers and transplant coordinators throughout Florida to ensure successful transplant outcomes for my patients
- Assist patients in identifying community resources that may benefit their overall health and wellbeing and ease financial strain
- Maintain an interdisciplinary approach for patient care by having ongoing collaboration with patient's care team and medical providers for continuity of care
Social Worker - DUO Health - Tampa, FL
(2023-11 - 2025-04)
Working remotely from home with predominantly chronic kidney disease patients at varies stages of illness and treatment as well as patients with other chronic illnesses. Conduct in-home, telehealth and phone assessments. Initial assessments of new patients as well as annual assessments with the engaged patients.
- Serving patients in Hillsborough, Manatee, and Pinellas Counties
- Provide therapeutic services as needed
- Conduct home visits as needed
- Visit patients in diverse settings such as hospitals, SNFs, and ALFs, and personal homes
- Create and maintain individual care plans for patients
- Connect with patients to outside services such as transportation, housing, and mental health programs
- Complete referrals for state funded programs, Medicaid HBCS programs, etc.
- Complete daily documentation for assessments, phone calls and progress notes
- Work with physician offices and insurance companies to ensure continuity of care
- Handle a 200+ participant caseload
- Participate in team decision-making daily
- Able to navigate multiple EMR systems such as Zus, Canvas and ECW
- Able to multi-task on a daily basis
- Assist in transition of care and discharge planning for patients transitioning from the hospital to a SNF or back to home
Social Worker - Suncoast PACE -Empath Health - Pinellas Park, FL
(2022-03 - 2023-04)
Conduct Bio-Psycho-Social assessments of new applicants as well as semi-annual and annual assessments with the program's members
- Provide counseling services as needed to participants
- Conduct home visits as needed
- Make routine visits to PACE contracted nursing homes to conduct assessments as well as friendly visits to participants in both skilled and long term care beds
- Create and maintain individual care plans for participants
- Connect with participants to outside services such as financial management, transportation, and housing
- Initiate and facilitate family meetings as well as assist in finding appropriate interventions to complex issues
- Complete state required documentations for enrollments, disenrollments, assessments, and progress notes
- Handle a 60-65 participant caseload
- Participate in team decision-making daily
- Able to multi-task on a daily basis
- Maintain a rapport with local Area Agencies on Aging and County Assistance Office
- Conduct Discharge planning for member transitioning from the hospital to a SNF or back to home
- Assist families in making end of life decisions for their loved ones
Director of Social Services - Corner View Nursing and Rehabilitation - Pittsburgh, PA
(2021-01 - 2022-02)
- Completion Assessments: initial, quarterly, annuals
- MDS documentation per state requirement
- Discharge planning with resident/family
- Care Planning
- State documentation and reporting
- PASRR Completion, Target reporting monitoring and Determination requests
- Initiate and conduct family meetings for care conferences, complaints & grievances, and provide resident updates upon request
- Hospice Planning in-facility and home
- Works closely with CHC MCOs to review resident cases, provide updates, make referrals for the NHT Program
Director of Social Services - Meadowcrest Healthcare and Rehabilitation - Bethel Park, PA
(2020-08 - 2021-01)
- Completion of Admissions paperwork with new residents
- Completion Assessments: initial, quarterly, annuals
- MDS documentation per state requirement
- Discharge planning with resident/family
- Care Planning
- State documentation and reporting
- PASRR Completion and monitoring or target residents
- Medicaid Renewal application completes with residents/families
Social Worker - ADVANCED HOME HEALTH - Pittsburgh, PA
(2019-09 - 2020-01)
- Traveled to patient homes throughout Beaver County and some parts of Allegheny county to complete home visits
- Conducted Social work evaluations to new skilled patients
- Provided patients with resources in maintaining their independence in their homes
- Conducted social work follow up as needed to patients needing more assistance with needing additional resources in the community
- Completed documentation as per insurance regulations
Social Worker - AmeriHealth Caritas Pennsylvania - Pittsburgh, PA
(2019-01 - 2019-09)
Service Coordinator for the Community Health Choices Managed Care Program
- Conduct Home Visits throughout the Greater Pittsburgh Area
- Conduct Initial Assessments, quarterly reviews, and annual assessments
- Provide Service Coordination by connecting participants with needed services in their communities to remain independent in their homes
- Implement services for participants
- Order DME/Supplies
- Communicate with providers and venders daily to ensure continuity of care
- Caseload of 100+
- Work from home, able to stay organized, work independently to meet deadlines
- Document daily through an EMR system
Social Worker - UPMC - Pittsburgh, PA
(2017-09 - 2019-01)
Service Coordinator for the Community Health Choices Managed Care Program
- Conduct Home Visits throughout the Greater Pittsburgh Area
- Conduct Initial Assessments, quarterly reviews, and annual assessments
- Provide Service Coordination by connecting participants with needed services in their communities to remain independent in their homes
- Implement services for participants
- Order DME/Supplies
- Communicate with providers and venders daily to ensure continuity of care
- Caseload of 75 plus
- Work from home, able to stay organized, work independently to meet deadlines
- Document daily through an EMR system
Social Worker - LIFE Pittsburgh All Inclusive Adult Day Center A PACE Program - Pittsburgh, PA
(2015-06 - 2017-09)
Conduct Bio-Psycho-Social assessments of new applicants as well as semi-annual and annual assessments with the program's members
- Provide counseling services as needed to participants
- Conduct home visits as needed
- Make routine visits to LIFE's contracted nursing homes to conduct assessments as well as friendly visits to participants in both skilled and long term care beds
- Create and maintain individual care plans for participants
- Connect with participants to outside services such as financial management, transportation, and housing
- Initiate and conduct family meetings as well as assist in finding appropriate interventions to complex issues
- Complete state required documentations for enrollments, disenrollments, assessments, and progress notes
- Handle a 35-40 participant caseload
- Participate in team decision-making daily
- Able to multi-task on a daily basis
- Maintain a rapport with local Area Agencies on Aging and County Assistance Office
- Conduct Discharge planning for member transitioning from the hospital to a SNF or back to home
- Assist families in making end of life decisions for their loved ones
Director of Social Services - Regency Healthcare - Wilmington, DE
(2013-05 - 2015-06)
Provide social services short term and to long term patients. Handle a case load of approximately 100 residents.
- Coordinated discharge planning for short term patients as well as assisted long term residents in the transition back into the community using various resources such as Money Follows the Person and LIFE Programs
- Participated in weekly Care Conferences
- Experience with completing state required documentation
- Experience with completing bio-psycho-social assessments of new residents
- Coordinate care for residents using multiple systems and community resources
- Worked with staff, residents, and families in resolving complex problems
- Experience with MDS 3.0
Social Worker - Powerback Rehabilitation - Philadelphia, PA
(2012-05 - 2013-05)
Social Services Specialist, Powerback Rehabilitation
- Provided social services to short term and to long term patients/residents
- Handled a case load of approximately 60 residents
- Coordinated discharge planning for patients
- Participated in weekly Care Conferences
- Experience with completing state required documentation
- Experience with completing bio-psycho-social assessments of new residents
- Coordinated care for residents using multiple systems and community resources
- Worked with staff, residents, and families in resolving complex problems
- Experience with MDS 3.0
Social Worker - LIFE at Home All Inclusive Adult Day Center Program
(2010-10 - 2012-05)
Conduct Bio-Psycho-Social assessments of new applicants as well as semi-annual and annual assessments with the program's members
- Provide counseling services as needed to members
- Conduct home visits as needed
- Made routine visits to LIFE's contracted nursing homes to conduct assessments as well friendly visits to members in both skilled and long term care beds
- Created and maintain individual care plans for members
- Connect members to outside services such as financial management, transportation, and housing
- Initiated and conducted family meetings as well assisted in finding appropriate interventions to complex issues
- Complete state required documentations for enrollments, disenrollments, assessments, and progress notes
- Handle a 40-55 member caseload
- Participate in team decision-making daily
- Was able to multi-task on a daily basis
- Maintained a rapport with local Area Agencies on Aging and Counties Assistance Offices
- Assisted in the creation and implementation of various policies and procedures for LIFE at Home
- Conduct Discharge planning for member transitioning from the hospital to a SNF or back to home
- Assist families in making end of life decisions of their loved ones
Social Worker, COSA - County Office of Services
(2010-07 - 2010-10)
Temporary Position through Axion Temp Agency
- Assess the needs of new consumers as well as set up in-home personal care services to assist with ADLS and IADLS tasks
- Conducted state mandated reassessments annually
- Completed state mandated documentation on a regular basis
- Made Referrals to various providers and agencies in order to provide a continuum of care to consumers
- Ordered varies in-home DME and supplies for consumers
- Conducted monthly phone calls and home visits to consumers/caregivers to ensure their needs were being met and they were satisfied with their services
- Assist caregivers/ family members with referrals to local support groups and counseling services
- Set up respite support for caregivers at risk for burnout and overwhelming levels of stress
Social Worker - Mercy LIFE All Inclusive Adult Day Center A PACE Program
(2009-11 - 2010-04)
Conducted Bio-Psycho-Social assessments of new applicants as well as bi-yearly assessments with the program's participants
- Provided social services to participants
- Conducted home visits monthly
- Made monthly visits to LIFE's contracted nursing homes to conduct assessments
- Provide support services for participants and caregivers
- Created and maintain individual care plans for participants
- Connected participants to outside services such as financial management, transportation, and housing
- Initiated and attended family meetings as well assisted in finding appropriate interventions
- Complete state required documentations for enrollments, disenrollments, assessments, and progress notes
- Handled a 50+ caseload
- Participated in team decision-making daily
- Assisted in organizing Participants' Town Council
- Was able to multi-task on a daily basis
Director of Social Services - Redstone Highlands Skilled Nursing Facility - Philadelphia, PA
(2009-05 - 2009-08)
Temporary position, relocated to the Philadelphia area
- Coordinated discharge planning for residents
- Participated in weekly Care Conferences
- Experience with completing state required documentation
- Experience with completing bio-psycho-social assessments of new residents
- Gained experience with coordinating care for residents using multiple systems and community resources
- Worked with staff, residents, and families in resolving complex problems
- Helped residents and families with completing the Medical Assistance process
- Assisted and was involved with multiple organizational committees such as: Resident Council, Medicare Committee, Clinical Committee
