Regional Case Manager Registered Nurse

MediLodge•Grand Rapids, MI

7d•Remote

About The Position

The Regional Case Manager (RCM) Registered Nurse (RN) position is an opportunity to advance your case management career with a growing healthcare company. Prestige Healthcare, a leader in skilled nursing and rehabilitation services, is looking for a remote Regional Case Manager with a strong work ethic, exceptional organization skills, attention to detail, and the ability to thrive in a fast-paced environment. This role involves managing a caseload of managed care patients, reviewing clinical records, negotiating rates, exclusions, and length of stay with managed care organizations. The RCM serves as a liaison between regional and corporate managed care initiatives, collaborating with Operations, Marketing, Clinical Reimbursement, Therapy, Finance, and Billing to ensure adherence to company policies and procedures.

Requirements

Registered Nurse preferred.
Five years of experience with long-term care related managed care.
Ability to use personal computer and application software such as Excel and Microsoft Word.
Functional speech, vision and hearing.
Ability to communicate professionally and effectively with referral sources at all levels of the organization both orally and in written form.
Strong organizational skills.
Ability to organize and prioritize.
Able to work independently, self-motivated and goal oriented.
Demonstrates self-confidence.

Nice To Haves

A background in MDS is preferred.

Responsibilities

Review all managed care contracts executed for their facilities.
Understand and communicate the needs of the regional and center staff to the Director of Managed Care to assure consistency in direction and execution of managed care.
Establish relationships with managed care organization’s Case Managers, specific to region.
Review clinical record, identify and negotiate higher levels and exclusions, where applicable.
Negotiate all rates, levels and one-time contracts for defined health centers managed care patients.
Obtain authorization, re-authorization and notifications for all new managed care patients for health center.
Complete all required documentation associated with rates, levels of care, cuts and exhausts as required by managed care organization.
Complete and maintain Case Manager Log on a daily basis.
Communicate with centers the needed documentation for continued stay and patient cuts.
Participate with facilities weekly (telephonically or center visit) to review managed care patients.
Participate in monthly triple check meetings for final review of UB statements and billing of negotiated exclusions.
Train facility staff on pre-admission case management process specific to their regional contracts.
Work collaboratively with Sales and Marketing, Business Office, Therapy, and Clinical team to provide appropriate services needed within the definition of the managed care contract.
Assist with any audits by the managed care organizations in conjunction with Medical Review.
Performs other duties as assigned.