Utilization Management/Case Manager
- Medical, Dental, Vision and additional other voluntary benefits
- 401k with company match
- Generous Paid Leave Policy
- Daily Pay partner
- Coordinate and manage care for a caseload of SNF patients, ensuring timely authorizations and continued stay approvals.
- Collaborate with interdisciplinary care teams, including physicians, therapists, social workers, and payors, to promote seamless transitions and quality care.
- Obtain and manage insurance authorizations for inpatient SNF care, including commercial plans, Medicare Advantage, Medicaid, Workman’s Compensation, No-Fault, and Single Case Agreements (SCA).
- Negotiate reimbursement rates for non-contracted payors when necessary.
- Review and respond to denials and discrepancies in authorizations; prepare appeal documentation and participate in QIO or health plan-level appeals as needed.
- Identify patient care needs, assess insurance limitations, and work with the healthcare team to develop appropriate care plans.
- Advocate for patient access to appropriate services while maintaining compliance with insurance guidelines.
- Maintain accurate and up-to-date documentation in accordance with facility, insurance, and regulatory standards.
- Licensed Registered Nurse (RN) or equivalent clinical credential preferred.
- Minimum 2 years of case management experience, preferably in a SNF, hospital, or managed care setting.
- Strong knowledge of insurance authorization processes, managed care, and appeal strategies.
- Experience with Single Case Agreements, Workman’s Comp, and No-Fault contracts.
- Excellent communication, negotiation, and interdisciplinary collaboration skills.
- Proficient in electronic health records and case management software.
- Familiarity with CMS guidelines, QIO processes, and discharge planning protocols.
- Ability to manage a high-volume caseload with a proactive and organized approach.
- Knowledge of Medicare and Medicaid regulations specific to SNFs.
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