Monica Zamora
Streamwood
Summary
Dynamic Transitional Care Manager with extensive experience at Oak Street Health, skilled in care coordination and quality improvement. Bilingual in Spanish, I excel in developing individualized care plans that enhance patient outcomes and reduce readmissions. Proven ability to foster team collaboration and implement effective discharge planning strategies.
Overview
12
12
years of professional experience
1
1
Certification
Work History
Transitional Care Manager-Registered Nurse
Oak Street Health/CVS Health
07.2024 - Current
- Educated patients on medication management and post-treatment care procedures.
- Led care transitions for high-risk patients, ensuring continuity of services and improved health outcomes.
- Adhered to CMS, state specific and NCQA compliance criteria as related to Transitions of Care.
- Conducted structured clinical assessment to identify post-discharge needs, including; medications, specialist appointments, home health, DME, caregiver support, social determinants of health.
- Conducted medication reconciliation on behalf of the PCP.
- Addressed identified post-discharge needs directly or via collaboration with other team members .
Transitional Care Manager RN- Follow up After ED
Oak Street Health
06.2022 - 07.2024
- Documented patient information accurately in electronic health records systems.
- Educated patients and families on self-management strategies to support recovery and prevent readmissions.
- Documented patient assessment, evaluation and responses to therapy to facilitate therapeutic intervention.
- Evaluated patient histories, complaints, and current symptoms.
- Collaborated with interdisciplinary teams to evaluate and address the physical, emotional, and social needs of patients during transitions of care.
- Provided leadership, guidance and support to staff members.
- Educated patients and families on treatment plans, health management, and preventive care strategies.
Registered Nurse
Oak Street Health Clinic
04.2019 - 06.2022
- Delivered an exceptional patient experience through service, responsiveness and respectful care
- Collaborated with interdisciplinary teams to develop individualized care plans for diverse patient populations.
- Educated patients and families on treatment plans, procedures, and health management strategies.
- Conducted thorough assessments to determine patient conditions and prioritize nursing interventions effectively.
- Utilized critical thinking skills to prioritize nursing interventions based on patients'' acuity levels and individual needs.
- Assisted in the training and mentorship of new nursing staff members, contributing to a positive work environment and high-quality patient care.
- Prevented the spread of infections by consistently adhering to strict infection control protocols and educating patients on proper hygiene practices.
- Skillfully managed challenging patient situations using de-escalation techniques, crisis intervention strategies, and therapeutic communication skills.
- Advised patients and caregivers of proper wound management, discharge plan objectives, safe medication use, and disease management.
- Provided skilled, timely and level-headed emergency response to critically-ill patients.
- Responded to incoming telephonic requests in a dependable manner, ensuring responsiveness to their needs and exceeding expectations.
- Utilized standardized protocols for medication management, prescription refills and prior authorizations.
Registered Nurse-Urgent Care/Occupational Health Nurse
AMITA Health
01.2018 - 04.2019
- Administered medications and treatments according to established protocols and patient care plans.
- Monitored vital signs and clinical symptoms to assess patient conditions and adjust care as needed.
- Streamlined workflow processes, reducing wait times while maintaining high-quality care standards.
- Quickly responded to situations impacting safety and security to unit, actualizing crisis prevention interventions to control and de-escalate situations.
- Delivered high level of quality care to diverse populations while overseeing patient admission and triaging based on acuity and appropriate department admission.
- Equipped patients with tools and knowledge needed for speedy and sustained recovery.
- Performed triage on incoming patients and determined severity of injuries and illnesses.
- Conducted health assessments and screenings to identify employee health risks.
- Developed return-to-work plans tailored to individual needs that expedited recovery time after illness or injury.
- Employed nursing skills to evaluate patient care needs, prioritize treatment and maintain patient flow.
- Provided skilled, timely and level-headed emergency response to critically-ill patients.
- Educated family members and caregivers on patient care instructions.
Registered Nurse
Oak Street Health Clinic
08.2015 - 01.2018
- Provided competent nursing care by displaying proficiency in this role and executing job responsibilities in a safe and consistent manner
- Responded to incoming telephonic requests in a dependable manner, ensuring responsiveness to their needs and exceeding expectations
- Provided clinically competent triage and symptom management to patients
- Utilized standardized protocols for medication management, prescription refills and prior authorizations.
- Conducted thorough and accurate reviews of patient medications and update as needed
- Provided comprehensive education and direct patient care, particularly around chronic conditions
- Performed point of care testing, procedures and specimen collection including phlebotomy
Registered Nurse
Allergy, Sinus, and Asthma Professionals
10.2013 - 07.2015
- Scheduled and conducted allergy testing ordered by physicians; schedules ongoing immunotherapy
- Mixed vials for current allergy patients and gave scheduled injections
- Ordered allergen supplies for the Allergy Department, kept Allergy test sets current
- Updated patient chart with relevant medical data; documents in the electronic Medical Record (EMR)
- Documented progress of immunotherapy patients, conveyed any concerns to the appropriate physician, ensure patients had a yearly physician “follow-up” appointment, and that patients are complying in obtaining an “Epi-pen”
Education
Bachelor of Science - Nursing
Purdue University
Calumet, Indiana12-2015
Associate of Science - Nursing
Wilbur Wright College
Chicago, IL05-2013
Skills
- Bilingual in Spanish Language
- Medication reconciliation
- Care coordination
- Quality improvement
- Discharge planning
- Transition planning
- Problem-solving abilities
- Excellent communication
- Organizational skills
- Team collaboration
- Certified in CPR/AED
- Problem-solving
Certification
- Certified Case Manager, 5/2023
- Intravenous Infusion Certification, 8/2018
- NIOSH Spirometry Certification 03/2018
Languages
Spanish
Native or Bilingual
Timeline
Transitional Care Manager-Registered Nurse
Oak Street Health/CVS Health
07.2024 - Current
Transitional Care Manager RN- Follow up After ED
Oak Street Health
06.2022 - 07.2024
Registered Nurse
Oak Street Health Clinic
04.2019 - 06.2022
Registered Nurse-Urgent Care/Occupational Health Nurse
AMITA Health
01.2018 - 04.2019
Registered Nurse
Oak Street Health Clinic
08.2015 - 01.2018
Registered Nurse
Allergy, Sinus, and Asthma Professionals
10.2013 - 07.2015
Bachelor of Science - Nursing
Purdue University
Associate of Science - Nursing
Wilbur Wright College