As a Clinical Integration Nurse Case Manager, I have extensive experience coordinating care among physicians, specialists, and ancillary services to ensure seamless patient transitions. I prioritize communication, using EHR systems and interdisciplinary meetings to align treatment plans. My role involves assessing patient needs, identifying gaps in care, and collaborating with providers to optimize outcomes. For example, I successfully reduced hospital readmissions by 20% by implementing a standardized discharge process. My focus is always on patient-centered care, ensuring all providers are informed and engaged in the care continuum.

I begin with a comprehensive assessment, reviewing medical history, social determinants, and patient goals. Using evidence-based tools, I identify risks and barriers to care. I then collaborate with the patient, family, and care team to create a tailored plan, prioritizing measurable outcomes. For instance, for a diabetic patient, I might integrate dietary counseling, medication management, and regular follow-ups. My approach is dynamic, adjusting the plan as needs evolve. By involving patients in decision-making, I foster adherence and improve health outcomes.

I employ active listening, clear language, and cultural sensitivity to build trust and understanding. I use teach-back methods to confirm comprehension and provide written materials for reinforcement. For families, I schedule regular updates and encourage questions. In high-stress situations, I remain calm and empathetic, ensuring concerns are addressed. For example, with a non-English-speaking family, I utilized interpreter services to explain a complex treatment plan, improving their engagement. My goal is to empower patients and families with the knowledge to participate actively in care decisions.

I approach conflicts with empathy and patience, exploring the patient’s concerns while educating them on clinical rationale. I present alternatives when possible and involve ethics committees if needed. For example, a patient refused a recommended surgery due to fear; I arranged a meeting with the surgeon to address their worries, leading to acceptance. Balancing autonomy and safety is key—I document discussions thoroughly and seek interdisciplinary input to resolve disagreements while respecting patient rights.

In a previous role, I identified redundant diagnostic tests ordered by multiple providers. I implemented a shared care plan in the EHR, reducing duplicate tests by 15% and saving costs. I also educated providers on appropriate test utilization. Additionally, I streamlined post-discharge follow-ups, using telehealth for stable patients, which cut unnecessary clinic visits by 25%. These measures maintained quality while enhancing resource efficiency, demonstrating my ability to innovate within value-based care frameworks.