RN / Case Management Job in El Paso, Texas / Hospital
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Description
Standard Qualifications: Facility Description: Las Palmas Medical Center offers comprehensive services and special expertise in Emergency Room Medicine (Level III Trauma), Cardiology, Women's Services, Labor & Delivery, Neonatal Intensive Care, Neuroscience, Pediatric care, and Wound Care Management. Las Palmas Medical Center is also the only Kidney Transplant Center in the Region. Las Palmas Rehabilitation Hospital is a separate facility with newly renovated patient rooms, exercise equipment and cafeteria. The physicians, nurses and staff at our 325-bed facility are committed to caring for our community with compassionate, quality healthcare. 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. POSITION SUMMARY: 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. POPULATION SERVED: All patients admitted to the hospital, emergency room, or outpatient areas and their families and/or caregivers. ESSENTIAL FUNCTIONS: 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. 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. 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. 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 conferrin
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