Lana B.

Conduct Individual Therapy Sessions Deliver evidence-based interventions (e.g., CBT, DBT, psychoeducation) tailored to client needs. Maintain a trauma-informed, culturally responsive, and strengths-based approach. Monitor progress toward measurable treatment goals. Complete Clinical Documentation Write timely and accurate progress notes using standardized formats. Complete biopsychosocial assessments to inform diagnosis and treatment planning. Document all observed behaviors, therapeutic interventions, and client responses. Develop and Maintain Treatment Plans Create individualized treatment plans with clear, measurable objectives. Update plans regularly based on client progress, feedback, and clinical review. Align goals with diagnostic criteria, functional impairments, and recovery milestones. Collaborate with Medical Providers Coordinate care with Nurse Practitioners and Psychiatrists to support medication management and integrated treatment. Share clinical observations and treatment updates to inform holistic care. Participate in multidisciplinary team meetings and case conferences. Support Recovery and Continuity of Care Engage clients in discharge planning and aftercare coordination. Refer to community-based services, peer support, and wraparound resources as needed. Advocate for client needs within managed care frameworks.

 Conduct individual therapy sessions.  Complete progress notes and biopsychosocial as needed.  Document all behaviors, interventions and responses Prepare individual treatment plans.  Collaborate with Nurse Practitioner and Psychiatrist to assist patients in recovery.

 Collaborated with a multidisciplinary team to validate the care treatment plan.  Monitored and updates the effectiveness of care treatment plan as the Member’s needs change.  Addressed the psychosocial needs of Members and make referrals to community resources.  Completed all documentation in accordance with the policies and procedures of North Shore-LIJ Health Plan, NY State and Federal regulations.  Ensured quality, member, safety and satisfaction in a fiscally responsible manner consistent with the health plan’s mission.  Referred Members to community centers, organizations, medical facilities, skilled nursing facilities and rehabilitation centers.  Conducted Care Management home and community based visits.  On-call on a monthly basis for after-hours discharge planning from hospital setting, assistance with transportation requests, and grievances.

 Responsible for discharge planning of MLTCP residents from hospital to community or skilled nursing facility.  Provided counseling to Members on various issues such as life transition to end of life.  Managed operational process for care management programs including complex care, chronic care, palliative care and care transitions programs.  Obtained and organized information from multiple sources including members, caregivers, physicians, clinical information systems and electronic health records.  Used information systems in accordance with operating procedures to document work activity.  Completed disenrollment documents including voluntary and involuntary disenrollment’s for Montefiore/SHP Members.  Authorized durable medical supplies, transportation, visiting nurse service, physical therapy, occupational therapy, social day care, home delivered meals and Social Work services for Members.

 Provided initial psychosocial assessments of new members or caregivers, including short-term individual and family counseling, community resource planning and crisis intervention  Utilized Geriatric Depression Scale, Mini Mental and Mini Cog to assess members mental status  Participated in the development of establishing a care plan for members  Established the social work component of the member/family plan of care based on goals mutually acceptable to the member, family and significant others.  Educated and assesses members/family understanding and ability to pay their Medicaid surplus payment, as appropriate  Documented services in accordance with VNS CHOICE Community Care standards and Managed Long Term Care regulations.

 Provide clinical and administrative supervision to five Case Planners  Input accurate and timely information regarding clients and service providers into Connections  Monitoring monthly calendar of caseworker’s activities which relate to mandated client contacts  Responsible for ongoing evaluation of the worker’s professional performance  Planning group conferences with assigned workers on a monthly basis to review agency, NYSDSS and ACS policy/procedural requirements  Ensure case work activity is completed in the absence of Case Planner

 Maintained and updated a complete case record for each client  Ensured full and timely written and verbal communication with ACS on all case aspects and developments  Prepared documents, such as progress notes, plan amendments, risk assessment forms and various group reports  Conducted at least two office visits and two home visits per month  Responded to client crisis within or outside work hours  Completed data entry for PROMIS and CONNECTIONS caseload  Facilitated Parenting Journey, an on site parent support group  Assisted in the coordination and facilitation of Family Team Conferences  Attended weekly Supervision to report on case for discussion of problems, difficulties or unresolved issues with clients  Coordinated and implemented casework conferences, as needed  Participated in staff meetings, seminars and trainings  maintained and applied knowledge of internal and external policies to applicable Preventive Services