Case Manager

Grand Terrace

Come join our team and start making a difference!

Admissions and Authorization Management

• Review referrals and clinical documentation to determine appropriateness for SNF admission.
• Coordinate pre-admission assessments and payer eligibility verification.
• Obtain and manage insurance authorizations for Medicare Advantage, Managed Care, Commercial, and other payer sources.
• Collaborate with hospital discharge planners, physicians, and referral sources to facilitate and streamline care transition to SNF.
• Ensure timely communication with payers regarding clinical updates and authorization requests.

Clinical Reimbursement and Care Coordination

• Lead and coordinate resident care planning activities with the interdisciplinary team.
• Participate in daily clinical meetings, utilization reviews, and care conferences.
• Monitor resident progress toward established goals and discharge plans.
• Identify barriers to care and implement interventions to improve outcomes.
• Facilitate communication among residents, families, physicians, therapists, nursing staff, and managed care companies.
• Section GG and PDPM Leadership
• Serve as the clinical champion and facilitator for initial and discharge Section GG function score meetings.
• Drive interdisciplinary collaboration between nursing, therapy, and MDS to ensure precise, accurate, and compliant functional scoring that reflects true patient care needs.

Utilization and Length of Stay Management

• Monitor resident length of stay and utilization of services.
• Conduct concurrent reviews to ensure medical necessity and continued skilled coverage.
• Submit clinical updates and supporting documentation to managed care companies.
• Track authorization expirations and ensure uninterrupted coverage.
• Analyze payer trends and identify opportunities to optimize reimbursement and resident outcomes.
• Utilization Defense: Utilize objective clinical and functional data to build robust clinical justifications for continued skilled stay, effectively communicating functional deficits to managed care payers during concurrent reviews.
• Peer-to-Peer and Appeals Managements: Must have the clinical acumen to assist prepping the Medical Director for peer-to-peer reviews and execute expedited appeals when a managed care organization issues an inappropriate discharge.

Discharge Planning and Care Transitions

• Coordinate with IDT on individualized discharge plans upon admission.
• Coordinate safe and effective transitions to home, assisted living, long-term care, or other settings.
• Arrange community resources, durable medical equipment, home health services, and follow-up appointments.
• Educate residents and families regarding discharge expectations and available resources.
• Monitor readmission risks and implement strategies to reduce avoidable hospitalizations.

Regulatory and Compliance Responsibilities

• Maintain compliance with CMS, Medicare, Medicaid, state regulations, and managed care requirements.
• Ensure accurate and timely documentation supporting skilled services and payer requirements.
• Participate in audits, surveys, and quality improvement initiatives.
• Maintain confidentiality and comply with HIPAA regulations.

Quality and Performance Management

• Monitor key performance indicators including:
• Average Length of Stay (ALOS)
• Readmission Rates
• Authorization Denial Rates
• Managed Care Performance Metrics
• Discharge-to-Community Outcomes
• Quality Measures Outcomes
• Participate in process improvement initiatives to enhance resident care and operational performance.
• Support facility goals related to quality measures and value-based care programs.

For benefit details check us out here http://ensignbenefits.com/

Benefits eligibility for some benefits dependent on full time employment status.

Disclaimer: Pay rates are competitive and determined by various factors. Please note that any rates labeled as "estimated" are provided by third-party job boards and may not accurately reflect the actual pay rates.

EOE disability veteran