Health Insurance Case Manager

Avalon Health Care•Washington, PA

4h•$81,000 - $110,000

About The Position

Avalon Health Care Management is now hiring a Case Manager of Utilization Management and Authorizations to join our team! Avalon Health Care Management is hiring an experienced Case Manager to join our team. This role is critical to supporting our Skilled Nursing Facility (SNF) operations by managing authorizations, utilization management, concurrent review, and payor coordination while ensuring smooth transitions of care. The Case Manager serves as a key liaison between physicians, interdisciplinary care teams (IDT), payors, and discharge planners. This position ensures timely communication of patient progress, and determination of medical necessity while supporting optimal outcomes and revenue integrity.

Requirements

Associate degree in a health or human services field preferred
Certified Case Manager (CCM) credential issued by the Commission for Case Manager Certification (CCMC) preferred
Minimum two (2) years of medical or utilization management case management experience preferred
Comprehensive knowledge and prior experience working with: Health Plans Managed Care Organizations (MCOs) Third Party Administrators (TPAs) Medicare Advantage and HMO plans Risk-bearing entities including: Medical Groups Independent Physician Associations (IPAs) Hospital-owned health plans (e.g., Kaiser, Select Health)
Ability to negotiate rates and provide complete, timely case management reports
Strong oral and written communication skills required

Nice To Haves

Familiarity with long-term care and/or sub-acute care strongly preferred
Nursing background strongly preferred for level-of-care determination

Responsibilities

Serve as a critical part of the pre-admission process, including: Pre-admission Payor authorizations Insurance verification Single Case Agreements (SCA’s)/Letters of Agreement(LOA’s)
Perform Utilization Management (UM) activities, including level-of-care determination
Conduct concurrent reviews, obtaining accurate and timely clinical information from physicians, therapy, and IDT and communicating updates to payors as directed
Negotiate appropriate levels of care within contract terms with payor case managers
Utilize SCA/LOA for non-contracted payor arrangements
Act as a liaison between payors and internal decision-makers to ensure clear, accurate, and timely exchange of information
Coordinate and communicate patient progress, expected discharge plans, and transitions to the next level of care
Provide complete, accurate, and timely case management documentation and reports to payors, IDT, and billing staff
Monitor records requested by insurance providers to ensure completeness and compliance
Network through professional case management organizations and attend community meetings regularly
Maintain a primary focus on census development and revenue enhancement