Case Manager

Ensign Services•McAllen, TX

12d•Onsite

About The Position

Come join our team and start making a difference! This role involves comprehensive case management within a skilled nursing facility, focusing on admissions, authorization management, clinical reimbursement, care coordination, utilization management, discharge planning, and regulatory compliance. The Case Manager will play a key role in ensuring accurate functional scoring, optimizing reimbursement, and facilitating smooth care transitions for residents.

Requirements

Clinical acumen to assist prepping the Medical Director for peer-to-peer reviews.
Ability to execute expedited appeals when a managed care organization issues an inappropriate discharge.
Accurate and timely documentation supporting skilled services and payer requirements.
Compliance with CMS, Medicare, Medicaid, state regulations, and managed care requirements.
HIPAA regulations compliance.

Nice To Haves

Experience with Medicare Advantage, Managed Care, Commercial, and other payer sources.
Experience with Section GG and PDPM.
Experience in utilization defense and appeals management.

Responsibilities

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.
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.
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.
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.
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.
Assist prepping the Medical Director for peer-to-peer reviews and execute expedited appeals when a managed care organization issues an inappropriate discharge.
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.
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.
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.