Case Manager

Skilled Wound Care•Los Angeles, CA

13h

About The Position

The Case Manager – SNF & Insurance Coordination is responsible for investigating and resolving complex insurance coverage issues for patients receiving care in Skilled Nursing Facilities. This role focuses on situations where coverage is incomplete, unverified, or unbillable through standard processes — including patients with Medicare Part A only, no insurance, or placement in hospital-owned or county facilities — and works directly with facilities and payers to identify viable billing solutions.

Requirements

High school diploma or equivalent required
Minimum 2 years of experience in medical billing, insurance verification, or case management
Working knowledge of Medicare Part A and Part B coverage rules, particularly as they apply to SNF stays
Experience identifying and resolving insurance coverage gaps or unspecified payer accounts
Familiarity with county hospital systems and hospital-based nursing facility billing limitations
Strong communication and negotiation skills, particularly when contacting external facilities and payers
Ability to manage and prioritize a high volume of accounts independently

Nice To Haves

Associate's or Bachelor's degree in healthcare administration, business, or a related field
Experience working in a billing, credentialing, or revenue cycle environment
Knowledge of Medicaid billing requirements and managed care payer processes
Certified Case Manager (CCM) or experience in utilization review
Proficiency with electronic health record and practice management systems (e.g., Epic, Cerner, PointClickCare)
Experience establishing direct billing arrangements with facilities

Responsibilities

Negotiate and establish direct billing agreements or arrangements with facilities where applicable
Document all outreach, agreements, and billing resolutions in the appropriate systems
Serve as the primary point of contact between the billing department and SNF facilities for unresolved or problematic accounts
Verify insurance eligibility and coverage details for patients with unclear or unspecified payer information
Identify patients who have Medicare Part A only and determine appropriate next steps for coverage or billing
Work with payers, Medicaid, and managed care plans to resolve coverage disputes and clarify billing responsibility
Manage insurance denials and appeals related to SNF stays and coverage determinations
Maintain accurate and timely documentation of all account activity, outreach efforts, and resolution outcomes
Ensure all billing and outreach activities comply with HIPAA, CMS guidelines, and applicable state and federal regulations
Track and report key metrics to leadership on coverage resolution outcomes and outstanding issues
Participate in billing and credentialing meetings to provide updates and flag trends in coverage gaps
Work closely with the billing and credentialing team to identify and prioritize complex coverage cases
Collaborate with clinical staff, social workers, and care coordinators to obtain information needed to resolve coverage issues
Provide feedback to leadership on recurring billing issues or systemic coverage gaps that require process changes