Dynamic Registered Nurse excelling in comprehensive patient assessments and chronic disease management. Proven ability to reduce readmissions through effective care coordination and strong communication skills. Committed to delivering quality, compassionate care while advocating for patients' needs and addressing barriers to health.
Overview
15
15
years of professional experience
Work History
Registered Nurse, Care Coordinator
Medical University Of South Carolina
10.2019 - Current
Coordinate comprehensive transitions of care for high-risk patients from inpatient to outpatient settings to reduce 30-day readmissions.
Conduct post-discharge follow-up within 24–72 hours, including medication reconciliation and symptom assessment.
Escalate acute clinical concerns promptly to providers, preventing complications and avoidable readmissions.
Collaborate with interdisciplinary teams (physicians, APRNs, case managers, social workers, pharmacists) to ensure continuity of care.
Advocate for patients by addressing barriers to care, including health literacy, transportation, and access to medications
Identify high-risk patients using EHR data and risk stratification tools to prioritize outreach and intervention.
Facilitate timely follow-up appointments and referrals to specialty and community resources.
Educate patients and families on red flag symptoms, medication adherence, and self-management strategies to improve outcomes.
Registered Nurse, Chronic Care Management
Medical University of South Carolina
10.2019 - 09.2025
Provided longitudinal care coordination for patients with multiple chronic conditions including diabetes, CHF, COPD, and hypertension.
Conducted comprehensive health assessments addressing medical, psychosocial, and social determinants of health factors.
Developed and updated individualized care plans in collaboration with primary care providers.
Performed medication reconciliation and reinforced adherence to prevent adverse events and exacerbations.
Monitored patients via phone and telehealth to identify early signs of clinical deterioration.
Escalated urgent concerns promptly to providers to prevent hospitalizations and ED visits.
Delivered patient-centered education on disease management, lifestyle modification, and symptom recognition.
Documented assessments, care plans, and interventions in Epic EHR.
Advocated for patients by addressing barriers to care, including health literacy, transportation, and access to medications
Evaluated patient histories, complaints, and current symptoms.
Explained course of care and medication side effects to patients and caregivers in easy-to-understand terms.
Facilitated therapeutic communication, conflict resolution and crisis intervention by redirecting negative behaviors and helping patients regain or improve coping abilities.
Educated family members and caregivers on patient care instructions.
Registered Nurse, Case Management
Vibra Hospital
01.2018 - 10.2019
Coordinated care for medically complex patients in a long-term acute care/rehabilitation setting to support safe recovery and discharge.
Performed comprehensive nursing assessments to evaluate clinical stability, functional progress, and discharge readiness.
Collaborated with physicians, bedside nurses, therapy services, and social work to develop and implement individualized care plans.
Supported multidisciplinary development of individualized care plans, including identification of psychosocial needs and community supports.
Mentored or collaborated with clinical teams to optimize patient outcomes and improve service delivery efficiencies.
Identified and addressed barriers to discharge including medical, psychosocial, and resource-related concerns.
Facilitated safe transitions of care to home, skilled nursing facilities, or rehabilitation centers.
Monitored patient progress and escalated clinical concerns promptly to providers to prevent complications.
Conducted utilization review to ensure appropriate level of care and adherence to regulatory standards.
Educated patients and families regarding disease processes, treatment plans, and post-discharge expectations.
Maintained accurate and timely documentation in the electronic medical record.
Transitional Hospice Registered Nurse
Intrepid Hospice
01.2015 - 01.2018
Developed and headed the hospice transitional care program which was then adopted company wide.
Worked closely with home health to identify hospice appropriate patients and facilitate smooth transition of care onto hospice services.
Conducted comprehensive nursing assessments for patients transitioning into hospice services, evaluating symptom burden, functional status, and individualized care needs.
Conducted nursing assessment to determine hospice eligibility and completed patient admissions.
Facilitated smooth transitions from hospital, skilled nursing, or home health settings into hospice care.
Collaborated with interdisciplinary hospice team members including physicians, social workers, chaplains, and aides to develop and implement patient-centered care plans.
Provided skilled symptom management and pain control interventions consistent with hospice and palliative care best practices.
Educated patients and families on hospice philosophy, medication regimens, disease progression, and end-of-life expectations.
Coordinated and conducted community educational events to promote awareness of hospice services, dispel myths, and foster informed decision-making regarding end-of-life care options.
Offered emotional support and counseling to patients and families during end-of-life transitions.
Advocated for patient comfort, dignity, and quality of life throughout the transition process.
Provided skilled symptom management and pain control interventions consistent with hospice and palliative care best practices.
Registered Nurse, Acute Rehab PRN
Roper Rehabilitation Hospital
07.2014 - 01.2015
Delivered comprehensive, patient-centered nursing care to adult patients in an acute inpatient rehabilitation setting.
Performed detailed admission, ongoing, and discharge assessments to evaluate clinical status and functional progress.
Developed and implemented individualized plans of care in collaboration with physicians, physical/occupational therapists, speech therapists, and case management.
Administered medications and treatments safely in accordance with evidence-based practice and organizational protocols.
Monitored patients with complex medical conditions (stroke, traumatic brain injury, spinal cord injury, orthopedic recovery, etc) and promptly escalated changes in condition.
Promoted functional recovery by reinforcing therapy goals and encouraging patient participation in rehabilitation activities.
Educated patients and families regarding disease processes, medications, discharge planning, and recovery expectations.
Coordinated interdisciplinary care to ensure continuity, safety, and optimal patient outcomes.
Maintained accurate and timely documentation in the electronic medical record.
Participated in quality improvement and patient safety initiatives to enhance care delivery.
Clinical Liaison, Registered Nurse
HealthSouth Rehabilitation Hospital
09.2012 - 07.2014
Conducted comprehensive clinical assessments of hospitalized patients to evaluate medical stability, functional deficits, and rehabilitation needs.
Reviewed complex medical records, lab results, imaging, and therapy documentation to determine appropriate level of care.
Collaborated closely with hospital physicians, bedside nurses, case managers, and therapy teams to coordinate safe transitions of care.
Utilized strong clinical judgment to identify patients appropriate for acute inpatient rehabilitation and escalate concerns when instability was identified.
Educated patients and families regarding diagnosis, recovery expectations, and post-acute care planning.
Advocated for patient-centered care decisions to ensure safe discharge planning and continuity of treatment.
Maintained detailed and accurate documentation of assessments and clinical recommendations.
Strengthened interdisciplinary communication to support quality outcomes and reduce delays in patient progression.
Registered Nurse, Acute Rehabilitation
HealthSouth Rehabilitation Hospital
01.2012 - 07.2014
Provided comprehensive nursing care to patients in an inpatient acute rehabilitation setting recovering from stroke, spinal cord injury, traumatic brain injury, orthopedic surgery, and complex medical conditions.
Performed thorough admission, ongoing, and discharge assessments to evaluate clinical status and functional progress.
Developed and implemented individualized care plans in collaboration with physicians, therapists, and case management.
Administered medications, IV therapies, enteral feedings, wound care, and other treatments in accordance with rehabilitation nursing standards.
Monitored for changes in condition and utilized critical thinking skills to escalate concerns and prevent complications.
Reinforced therapy goals and promoted patient participation to maximize functional independence.
Educated patients and caregivers on disease processes, medication management, safety precautions, and discharge planning.
Coordinated interdisciplinary communication to support safe transitions and optimal patient outcomes.
Maintained accurate and timely documentation in the electronic medical record.
Participated in quality improvement and patient safety initiatives.
Delivered direct patient care to individuals recovering from stroke, orthopedic surgery, neurological injury, and complex medical conditions in an inpatient rehabilitation setting.
Assisted Registered Nurses in developing and implementing individualized plans of care to support recovery and functional independence.
Administered prescribed medications and treatments in accordance with physician orders and scope of practice.
Monitored vital signs, blood glucose levels, wound healing, and overall patient status; promptly reported changes in condition to supervising RN or provider.
Performed skilled nursing interventions including wound care, catheter care, tracheostomy care, and enteral feeding management.
Reinforced therapy goals and promoted patient participation in rehabilitation activities.
Educated patients and caregivers on medications, safety precautions, and discharge instructions under RN guidance.
Maintained accurate, timely documentation in the electronic medical record.
Education
Master of Science - Nursing, Adult Geriatric Primary Care NP
Registered Nurse | Acute Care / Complex Discharge Unit at University of Kentucky Good Samaritan HospitalRegistered Nurse | Acute Care / Complex Discharge Unit at University of Kentucky Good Samaritan Hospital