Susan Smith

Experienced nursing professional with over 15 years on clinical and supervisory roles, combining knowledge with hands-on-expertise. Dedicated to delivering high-quality patient care and leading healthcare teams in fast-paced environments.

CARE COORDINATOR/CASE MANAGER at NaviHealth/Optum Home and Community (2023-06 – Present)

• Assessment and Care Planning: Develop individualized, evidence-based care plans. Comprehensive biopsychosocial and clinical assessments in collaboration with patients and their support networks.
• Coordination of Care: Schedule and manage appointments and referrals, ensuring patients receive the right care at the right time. This includes coordinating multidisciplinary care team meetings with Physicians, nurses, social workers, therapists, etc.
• Patient Education and Advocacy: Educate patients and families about treatment options, medication management, lifestyle changes, and available resources.
• Track patient progress, monitor adherence to care plans, and adjust interventions as needed to ensure safe transitions across settings such as hospital to home or outpatient to specialty care.
• Documentation and Data Management: Maintain accurate records in EMR, documenting assessments, care plans, interactions, and outcomes.

MDS RN at Optalis/Promedica Allen Park (2022-04 – 2023-06)

• Assessment Management: Conduct and coordinate MDS assessments using resident interviews, chart reviews, and interdisciplinary input.
• Track and maintain assessment schedules (5‑day, 14‑day, quarterly, annual, significant change).
• Care Planning: Develop individualized care plans based on MDS data. Update care plans as conditions change.
• Regulatory Compliance: Ensure adherence to CMS, Medicare, Medicaid, OBRA, and state regulations.
• Maintain accurate documentation and meet strict federal deadlines.
• Data Submission & Quality Assurance: Submit assessments electronically through QIES/ASAP systems.
• Interdisciplinary Collaboration: Communicate with nursing, therapy, social services, dietary, and administrative teams.
• Identify skilled services and ensure documentation supports reimbursement.

NURSE SUPERVISOR at Optalis/Promedica/Heartland (2011-07 – 2023-06)

• Serve as a super user, supporting facility with technical support and troubleshooting.
• Deliver Hospice care and support to family members to support passionate end of life care.
• Coordinate Admissions and Discharge according to facility protocol.
• Collaborate with Physicians to implement interventions, evaluate, and monitor progress for optimal outcomes.
• Report changes to the team ensuring timely communication and continuity of care.

RESPITE HOMECARE at Generations Home Care

• Provide respite care for families with terminally ill children.
• Educated families in areas such as Infection control, Safety, Health Promotion, and Nutrition.
• Work in teams with Physicians and personnel to follow plan of care and implement Physicians' orders.

MEDICAL BILLER at American Billing Consultants

• Coordinate billing for Hospitals, Nursing homes, Doctors' office claims, and Home visits.

MASTER of PUBLIC HEALTH in Public Health – Oakland University

BACHELOR of SCIENCE in NURSING in Nursing – Oakland University

ASSOCIATE of APPLIED SCIENCE – Wayne County Community College