Since 1974, Del Sol Medical Center has provided quality healthcare to El Paso and the surrounding region. As a full service, acute care hospital in East El Paso with a Level II Trauma designation in Emergency Services, we continue to expand our services to meet the growing needs of our tristate community, providing special expertise in Cardiology, Maternity & Child Services, a Level III NICU, a Center of Excellence designation for our Bariatric Clinic, a Level II Trauma Center, and a newly renovated 32 bed Rehabilitation Hospital.
The physicians, nurses and staff at our 350 bed hospital are committed to providing the highest quality care with compassion and integrity.
Las Palmas Medical Center is a Level III Trauma, 186 private patient room, full service acute care hospital. Las Palmas Medical Center offers comprehensive healthcare and provides leading edge technologies. Our Lifecare Center offers inpatient and outpatient rehabilitation programs, as well as our fully equipped fitness and wellness center in one convenient location. We also house the region's only Kidney Transplant Center.
We are located on the Westside of El Paso, Texas close to the University of Texas El Paso campus. We provide exceptional patient care services to the El Paso and Fort Bliss communities, as well as Southern New Mexico and West Texas Regions.
Provides overall coordination in the delivery of medical services and discharge planning for a specified patient population. Performs concurrent and retrospective review of patient medical records for purposes of utilization review, compliance with requirements of external review agencies including governmental and non governmental payers and quality assurance agencies. Promotes a cooperative and supportive relationship as liaison with patient, family, facility staff, physicians, funding representatives and community agencies. Ensures continuity in the handoff of patient clinical information from the hospital to other involved healthcare entities. The duties of the acute care Case Manager may be performed as in the integrated or triad model.
All patients admitted to the hospital, emergency room, or outpatient areas and their families and/or caregivers.
Financial Assessment and Coordination
Communicates proactively and cooperatively with Patient Access, Patient Account Services (PAS) and Central Verification Office (CVO) personnel to ensure proper pre certification and consistency of admissions status designation between physician order and EMR.
Communicates known changes to patient payer information and other relevant financial characteristics of coverage to appropriate admissions and/or billing personnel.
c. Proactively ensures that required clinical justification is provided to third party payers to obtain recertification for continued hospitalization and treatment and that transfer of this information, together with days approved and contact information is provided timely to the PAS and CVO via computerized insurance review documentation.
d. Serves as liaison between third party payers, patient access PAS and CVO to ensure communication of all pertinent information regarding level of care, billing and reimbursement.
e. Works with the patient and family to identify alternate financial resources available to meet the cost of necessary post discharge needs or to recommend alternate care options when necessary funding is unavailable.
. Proactively initiates expedited appeals process with payers and communicates with denials management regarding anticipated or verified denials and cooperates with denials management to provide additional clinical information for appeals.
Treatment Planning and Coordination of Services
Educates patient and family on case manager role and process for contacting the case manager for questions.
Coordinates the integration of social services/case management functions into the patient care, discharge and home planning processes with other hospital departments, external service organizations, agencies and healthcare facilities.
Collaborates with clinical staff in the development and execution of the plan of care and achievement of goals.
Facilitates interdisciplinary patient care rounds and/or conferences to review treatment goals, optimize resource utilization, provide family education and identify post hospital needs.
Ensures that patient tests are appropriate and necessary and are carried out within the established time frame and that results are promptly available.
Serves as a patient advocate by enhancing a collaborative relationship to maximize the patient's and family's ability to make informed decisions.
Refers to social work cases where patients and/or family would benefit from counseling required to complete complex discharge plans.
Utilization Review, Quality and Compliance Monitoring
Conducts concurrent medical record review using specific quality indicators and clinical decision support criteria as approved by the medical staff, TJC, CMS and other regulatory agencies and document findings.
Serves as liaison with Physician Performance Improvement (PPI) to ensure the reporting of quality indicators and care concerns.
Initiates delivery of notices of non coverage as appropriate.
Reviews all new admissions daily against inpatient screening criteria and communicates necessary changes in status designation to ordering physician and Patient Access.
Identifies all observation patients with observation alert sticker, reviews status no less frequently than daily, and communicates directly with the attending physician if severity of illness and intensity of service meet criteria for inpatient admission or when observation hours threaten to exceed 48 hrs.
Communicates with treating physicians at regular intervals throughout hospitalization of the patient to develop an effective working relationship, while assisting physicians to maintain appropriate costs, utilization of resources, and discharge plans commensurate with the patient's available resources.
Ensures physician documentation supports medical necessity and LOC for each inpatient day, educates physicians by aggressively discussing additional documentation needs as identified or discharge plans and conferring with Case Management Director and Physician Advisor as needed for intervention.
Monitors and provides documentation of identified variance days for tracking and trending.
Stays current with education related to CMS and HCA billing compliance mandates, monitors and ensures that facility is compliant.
Facilitates delivery of CMS discharge appeals rights communication to applicable Medicare patients within indicated time frame required by law.
Provides retrospective chart review for short stay inpatients under Medicare for medical necessity and level of care prior to billing.
Discharge Planning and Continuity of Care
Collaborates with interdisciplinary care team, service liaisons, patient and family in the assessment and coordination of discharge planning needs, delivery of post discharge services and transition of the patient from an acute level of care to the discharge setting.
Facilitates delivery of Patient Information and Choice Letter to assure documentation of patient/family involvement with discharge planning and choice of post discharge service providers.
Facilitates the ordering and delivery of specialized medical equipment, orthotics and prosthetics as ordered by the attending physician.
Facilitates referral process of next level of care.
Attends meeting to review observation admissions, extended LOS, unfunded and underfunded, and anticipated difficult discharges.
Attends and actively participates in monthly staff meetings, and attends called departmental meetings when necessary.
Attends and participates in facility committees, employee forums and departmental meetings as requested.
Actively utilizes and complies with facility principles of good communication and customer service standards, including use of AIDET as developed by the department.
Maintains compliance with required licensure, ethics and compliance training, annual mandatory TB screening and mandatory education as required.
Prepares and presents inservice and training programs as requested.
Performs other duties as required.
REQUIRED LICENSURE/CERTIFICATIONS :
Current LVN or RN licensure; Preferred: BSN level of education.
(Required) Registered Nurse with clinically focused work history.
Prefer three five years clinical experience within an acute health care setting with recent work history in acute care case management role or related health care experience. Working knowledge of case management philosophy/process/role, needs assessment, principles of utilization review/quality assurance, use of InterQual® or other clinical decision support criteria, discharge planning, and reimbursement structures (i.e. Government and non governmental payers).
Ability to read, analyze and comprehend complex clinical and financial data and its application to level of care criteria and discharge options; strong, broad based clinical knowledge and understanding of pathology/physiology of disease processes; excellent critical thinking skills; assertive personality traits to facilitate ongoing physician communication; organize, prioritize and manage time efficiently. Computer literacy and familiarity with the operation of basic office equipment. Must be able to communicate effectively with a wide range of hospital personnel, physicians, patients/family members within various socioeconomic groups and representatives of varied outside agencies. Ability to communicate effectively with and know the age specific needs of patients of adolescent, adult and geriatric age.
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