Carrie DeFere
Napa,CA
Summary
Knowledgeable RN Case Manager with solid history of managing complex caseloads and providing comprehensive support to diverse client populations. Proven ability to assess client needs and develop tailored action plans that drive positive outcomes. Demonstrated strong communication and problem-solving skills in high-pressure environments.
Overview
24
24
years of professional experience
1
1
Certification
Work History
POPULATION HEALTH CASE MANAGER
NorthBay Medical
12.2014 - Current
- Identified High risk for readmission patients and followed along the continuum of care
- Advocated for patient needs by collaborating with interdisciplinary teams.
- Provided education and support to patients and families regarding treatment options and care transitions.
- Ensured continuity of care through effective communication between providers and community resources.
- Conducted thorough assessments to identify patient risks and needs.
- Complex Case Management of CHF, COPD, Sepsis and Diabetes patients
- Coordinated and facilitated SNF Roundtables biannually
- UR-MCG Initial and concurrent reviews
- Coordinated comprehensive care plans for patients, ensuring alignment with medical and social service needs.
- Mentored junior case managers on best practices in case handling and client interaction techniques.
- Advocated for patient rights and access to necessary healthcare resources within the community framework.
- Conducted thorough assessments of clients'' situations, identifying issues, goals, and necessary interventions.
CASE MANAGER
Sonoma Valley Hospital
02.2011 - 05.2019
- Developed “Transitions of Care” Program that focuses on re-admit and “frequent flyer patients
- Care Coordination with community partners and caregivers
- UR-MCG Initial and concurrent review
- Skills: Central line care, VAC dressings, lab draws, FC and SP catheter insertion.
- Conducted assessments to identify patient needs and monitor progress.
- Facilitated communication between patients, families, and healthcare providers.
- Implemented discharge planning processes to enhance patient transitions.
- Advocated for patients' rights and resources within the hospital system.
CASE MANAGER-HOME HEALTH
St. Joseph Home Care
02.2009 - 10.2011
- Coordinate comprehensive patient care in the home, acted as a central point for the care team (nurses, therapists, aides, doctors) to develop, implement, and monitor personalized care plans, ensuring continuity, managing documentation, educating families, and facilitating smooth transitions.
- Skills included wound care-VAC dressing changes, IV and Central line care, FC and G-tube care along with thorough patient assessments
CASE MANAGER-CLINICAL ACCESS
Adventist Health Hospital
05.2005 - 07.2006
- Screened patients wanting admission to the hospital
- Phone triage of pending admissions
- UR-Initial and concurrent reviews
- Prepared reports-Outlier, length of stay and care summaries
- Tracked metrics and patient progress
- Monitored progress of cases, ensuring compliance with hospital protocols and quality standards.
- Assessed patient needs and developed personalized support strategies for optimal resource utilization.
PROGRAM MANAGER CARDIAC REHABILITATION
Adventist Health Hospital
07.2002 - 05.2005
- Oversee day to day operations of program and personnel
- Marketing of program, developing policies and procedures
- Patient and Community Education and program development
- Analyzed program performance data, identifying areas for improvement and implementing effective solutions.
- Established metrics for program evaluation, driving accountability and enhancing service delivery standards.
- Managed and supervised administrative and daily program operations, complying with policies and regulations.
- Established strong relationships with key stakeholders, ensuring support for program initiatives.
Education
BSN -
California State East Bay
Hayward, CASkills
- Problem-solving
- Case management
- Time management
- Decision-making
- Conflict resolution
- Positive attitude
- Resource management
- Excellent communication
Certification
- Certified CCMC Commission For Case Manager Certification,
Timeline
POPULATION HEALTH CASE MANAGER
NorthBay Medical
12.2014 - Current
CASE MANAGER
Sonoma Valley Hospital
02.2011 - 05.2019
CASE MANAGER-HOME HEALTH
St. Joseph Home Care
02.2009 - 10.2011
CASE MANAGER-CLINICAL ACCESS
Adventist Health Hospital
05.2005 - 07.2006
PROGRAM MANAGER CARDIAC REHABILITATION
Adventist Health Hospital
07.2002 - 05.2005
BSN -
California State East Bay