Case Manager (Hybrid)

Case Manager (Hybrid)

The Case Manager (CM) plays an integral role in optimizing the plan of care for Managed Care patients. The Hybrid Case Manager (CM) is responsible for the timely compilation, review and submission of medical information relating to the post-acute skilled stay. By serving as the liaison between the patient, physician interdisciplinary care team members, and the payer; this position coordinates, monitors, advocates and communicates the patients progress and cost evaluation while assisting with and coordinating an efficient and smooth coordination to the next level of care.

Case Manager Responsibilities:

• Ensure Case Manager coverage is provided for each facility.

• Develop a comprehensive system to ensure clinical updates are complete and accurate before submission.

• Assess residents’ care needs and review documentation required for authorization to a Skilled Nursing Facility. Ensure documentation supports managed care/payor’s requirements (InterQual and Milliman Care Guidelines).

• Ability to review and understand contract terms and requirements for Skilled Nursing Services.

• Meet submission deadlines of concurrent reviews to the managed care payor.

• Assist facilities with the determination and facilitation of discharge planning/transition of care appropriateness for the patient (Home Health, DME, NOMNC/Non-Coverage Letters).

• Communicate continued stay matters and complex cases with internal facility staff (Utilization Review Committee) and managed care payor.

• Collaborate with internal facility team (Clinical, Therapy, Social Services, Admissions, Business Office, and Billing) to facilitate protocols/outcomes for managed care patients.

• Understand, interpret, and apply managed care payor contracts for the appropriate leveling of patients for reimbursement and any carve-out/stop loss clauses. Assist corporate billing department with billing issue on behalf of patients/members.

• Provide education as needed to individual facility staff members in relation to timely submissions, documentation, etc.

• Collaborate with nurse managers and regional and corporate team members to identify specific learning UR Meeting/documentation needs of the facilities, regions, or companywide.

• Prepare, participate, and assist with Quality Assurance and Performance Improvement (QAPI) programs, projects, meetings, and training.

Case Manager Qualifications:

• Must be an active license: RN/LPN

• Substantial work experience relevant to case management, care planning, discharge planning, and clinical chart reviews.

• Work experience in post-acute care, skilled nursing facilities, long-term care, or assisted living.

• Demonstrated leadership and supervisory skills in the areas of case management and employee relations management.

• Basic Knowledge of nursing and medical practices and procedures, as well as state and federal regulations specific to nursing home operation and licensure.

• Must possess leadership and supervisory ability and the willingness to work harmoniously with residents, families, vendors, visitors, government agencies, facility staff, hospital personnel, hospice representatives, and the general public.

• Must possess the ability to plan, organize, develop, implement, and interpret programs, goals, objectives, policies, and procedures, etc., that are necessary for providing quality individualized care.

• Ability to formulate reports, disseminate information, interpret data, and coordinate with multiple departments.

• Ability to read and interpret documents such as safety rules, operating and maintenance instructions and procedure manuals.

• Ability to solve practical problems and deal with a variety of concrete variables in situations where only limited standardization exists. Ability to interpret a variety of instructions furnished in written, oral, diagram or schedule form.

We offer a great benefits package, paid time off, competitive compensation, engaging work atmosphere, innovative training programs, excellent growth opportunities, caring culture, and environment, and so much more!

INDADM