Case Manager

About the Role

Join our team to manage admissions, clinical reimbursement, care coordination, and ensure compliance with regulatory standards in a skilled nursing facility (SNF). This role involves collaborating with interdisciplinary teams, payers, and external partners to optimize resident outcomes and facility performance.

Responsibilities

• Review referrals and clinical documentation to determine appropriateness for SNF admission.
• Coordinate pre-admission assessments and verify payer eligibility.
• 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 streamline care transitions 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 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.
• 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.
• Assist in preparing the Medical Director for peer-to-peer reviews and execute expedited appeals for inappropriate discharges.
• Coordinate with the interdisciplinary team on individualized discharge plans upon admission.
• Facilitate 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.

Benefits

Benefits eligibility for some benefits is dependent on full-time employment status. For details, visit Ensign Benefits.