LPN Case Manager

Position Summary

Overview:

The Licensed Practical Nurse (LPN) Case Manager plays an integral role in ensuring complex health cases are managed appropriately, along with continuity of care, preventing readmissions, and enhancing patient outcomes. This specialized position requires a unique blend of clinical and/or administrative nursing expertise, exceptional communication skills, and a compassionate, patient-centered approach.

Duties:

• Works with insurance companies and staff to obtain initial and ongoing authorizations for patients in advance of services.
• Researches, corrects, and resubmits rejected/denied insurance authorizations. Identifies missing, insufficient, or inconsistent clinical information and proactively obtains clarifications from providers.
• Reviews the accuracy and completeness of information requested to ensure that all supporting documents are present.
• Serves as a liaison between the prior authorization team, ordering providers, nursing staff and care coordination teams.
• Conducts clinically informed review of provider orders, documentation, and medical records to determine medical necessity based on payer guidelines and evidence-based criteria.
• Reviews denial trends and recommends clinical-focused process improvements to reduce avoidable denials.
• Care Management (Transition/Discharge Planning):
• Assesses patients' needs and creates comprehensive discharge/transition plans.
• Collaborates with healthcare providers to ensure continuity of care during transitions.
• Educates patients and families on post-discharge care instructions.
• Conducts follow-up calls and visits to ensure compliance with discharge plans.
• Identifies potential barriers to successful care transitions and develops solutions.
• Advocates for patient needs and preferences throughout the transition process.
• Documents and maintains detailed patient records and discharge/transition plans.

Knowledge, Skills, and Abilities

• Knowledge of:
• Center for Medicare and Medicaid Services (CMS) regulations.
• Electronic health record (EHR) systems.
• Case, care and utilization management principles and protocols.
• Community resources and support services provision

• Skill in:
• Clinical and/or administrative nursing or personal care.
• Knowledge of Microsoft Office Suite and basic computing systems.

• Ability to:
• Problem solve using logical reasoning or critical thinking aptitude.
• Communicate effectively both orally and in writing.
• Collaborate, interact and engage effectively with patients, residents, teams, and other stakeholders.
• Utilize interpersonal skills to acknowledge and support concerns and demonstrate empathy or understanding.
• Develop and implement care and case management plans.
• Be productive and plan, organize, and manage time effectively and efficiently.
• Advocate for, promote and protect the rights of patients and residents.
• Treat all residents with dignity and respect.
• Establish a culture of compliance by adhering to all facility policies and procedures.
• Comply with standards of business conduct and state/federal regulations and guidelines.

Minimum Requirements

• High School Diploma or its equivalent.
• Two (2) years clinical and/or administrative nursing experience which must include at least one (1) year of Case or Care Transition Management or Personal Care Management in a Long-Term Care (LTC)/Skilled Nursing Facility (SNF) or HealthCare (HC) setting.
• One (1) year of insurance Prior Authorization (PA) experience is also preferable.
• Current and valid Licensed Practical Nurse (LPN) license in the state of Pennsylvania is required and will be verified prior to appointment.

Residency

Not required to live in Allegheny County

Veterans' Preference

Will be awarded to eligible candidates.