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  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 We are a provider of skilled nursing and rehabilitative services and offer a work environment where our teams are empowered to achieve superior clinical outcomes and high resident/family satisfaction ratings. We strive to achieve these objectives by living our core values of Customer Second, Accountability, Passion for Learning, Intelligent Risk Taking, Celebration and Ownership. Our mission is, through moments of truth, to dignify long term and assisted care in the eyes of the world.

We are an equal opportunity employer committed to ensuring that all conditions and privileges of employment, including recruitment, hiring, evaluation, transfer, promotion, discipline, determination of compensation and/or benefits, and termination of employment, for all job classifications, are based on qualifications and work record. No employment decision is made, nor do we discriminate, on the basis of race, color, religion, creed, sex/pregnancy, sexual orientation, gender identity, gender expression, age, national origin, ancestry, citizenship,…