Clinical Case Manager

We are looking for a proactive Case Manager to join our team in a skilled nursing facility (SNF). The successful candidate will coordinate patient care, focusing on insurance authorizations, case management, and discharge planning. This role is crucial in ensuring services are covered, authorized, and managed effectively to achieve the best patient and financial outcomes.

• Patient Care Coordination: Manage the care of SNF patients, ensuring timely authorizations and approvals.
• Team Collaboration: Work closely with physicians, therapists, social workers, and insurance providers to ensure smooth transitions and high-quality care.
• Insurance Authorizations: Obtain and manage authorizations for various insurance plans, including commercial, Medicare Advantage, Medicaid, Workman’s Compensation, No-Fault, and Single Case Agreements (SCA).
• Rate Negotiation: Negotiate reimbursement rates for non-contracted payors when necessary.
• Appeals Management: Address denials and discrepancies in authorizations, prepare appeal documentation, and participate in appeals processes as needed.
• Care Planning: Identify patient care needs, assess insurance limitations, and collaborate with the healthcare team to develop appropriate care plans.
• Patient Advocacy: Advocate for patient access to necessary services while adhering to insurance guidelines.
• Documentation: Maintain accurate and up-to-date records in compliance with facility, insurance, and regulatory standards.

• Clinical Background: Preferably a Licensed Registered Nurse (RN) or equivalent clinical credential.
• Experience: At least 2 years of case management experience, ideally in an SNF, hospital, or managed care setting.
• Insurance Knowledge: Strong understanding of insurance authorization processes and appeal strategies.
• Skills: Excellent communication, negotiation, and collaboration skills.
• Technical Proficiency: Proficient in electronic health records and case management software.

• Regulatory Knowledge: Familiarity with CMS guidelines, QIO processes, and discharge planning protocols.
• Caseload Management: Ability to manage a high-volume caseload efficiently.
• Medicare/Medicaid/Commercial Insurance Expertise: Knowledge of regulations specific to SNFs.

• Environment: On-site or hybrid work environment
• Setting: Fast-paced, patient-centered setting with frequent interaction with healthcare professionals and insurance representatives.