Case Management/UR Nurse - FT

Improving Lives Together

Magruder Hospital offers competitive wages with a comprehensive benefit package available to both full-time and part-time employees. We provide a full health plan and generous time off that includes Holidays, Vacation, Sick, Personal, and even your Birthday! Our culture and family friendly work environment truly set us apart- apply today for an opportunity to join our team and help serve this great community!

Provides a patient and family centered approach to carry out essential duties and responsibilities. Coordinates the provision of care and services, maximizing the patient’s recuperative potential with his/her social context. Responsible for assisting in the appropriate assignment of patient classifications, i.e. inpatient, observation, ambulatory, etc. Participates in Transitional Care Program compliance. Initiates communication with patients’ insurance companies to meet the requirements for preauthorization and monitoring of length of stay.

Essential Duties & Responsibilities:

• Conducts intake assessments with patients and families.
• Ensures that families feel sufficiently equipped and supported.
• Develops individualized treatment plans with the interdisciplinary team that account for physical, financial, and other constraints.
• Suggests and coordinates appropriate follow-up services to promote wellness.
• Ensures that patients have transport to and from their homes and all pertinent healthcare facilities.
• Meets with members of healthcare teams to discuss patients' progress, and to deliberate on appropriate care.
• Checks to see whether patients have sufficient insurance coverage or finances to pay for their treatment and facilities resource access by providing information and assistance
• Devises innovative solutions or suggesting appropriate referrals for patients who cannot afford to access treatment.
• Familiarity with patient databases, local resources, and community navigation.
• Exceptional leadership, supervision, and motivational skills.
• Committed to promoting patients' well-being.

• Monitors documentation and works closely with the medical staff for appropriate level of care utilizing MCG criteria for admission justification, discharge assessment, and concurrent reviews and monitors progress throughout the patients hospitalization. Performs utilization review and payor notification in a timely manner, per established department work-flow, CMS, and/or payer-specific guidelines.

• Complies with CMS rules and regulations, Conditions of Participation, and payor-specific guidelines to prevent denials and revenue loss. Manages all concurrent denials, including determination of appeals.
• Complies with federal, state, and local legal requirements by studying existing and new legislation; anticipating legislation; enforcing adherence to requirements; advising management on needed actions; ensures compliance with Joint Commission and other external and internal regulatory agencies.
• Provides training to nurses and house supervisors on MCG as needed.

• Maintains the integrity of confidential patient information in accordance with HIPAA and hospital policy, including accessing, using and disclosing patient information relevant to the individual employee’s job duties. Also maintains confidentiality of other customer and hospital business affairs.
• Adheres to the standards of Magruder Hospital’s corporate compliance policies and seeks guidance and training when necessary to resolve questions about the policies. Reports violations in accordance with corporate compliance and organizational standards.
• Flexibility in works varied hours.
• Reports to work on time and as scheduled; Shows respect for co-workers by following established break times; Keeps personal conversations and telephone calls to a minimum.
• Travel is primarily local during the business day, although some out-of-area and overnight travel may be expected.
• Please note this job description is not designed to cover or contain a comprehensive listing of activities, duties or responsibilities that are required of the employee for this job. Duties, responsibilities and activities may change at any time with or without notice.

• All other duties as requested or assigned.