What are the responsibilities and job description for the Case Manager position at PACS?
General Purpose: Utilize clinical expertise and critical thinking skills to work collaboratively with facility interdisciplinary teams, healthcare providers, insurers, and other involved parties to oversee and ensure the delivery of skilled services for managed care members during their stay at the skilled nursing facility while being sensitive to cost and resources.
Note: This is a HYBRID role- at this time we will only consider applicants residing in the upstate area of South Carolina.
Essential Duties:
- Communicate regularly with facility IDT about members' plans of care, PT, OT, and other treatment protocols.
- Attends and participates in morning meetings/stand up and IDT meetings to facilitate communication with the team.
- Attends and participates in meetings with facility IDT and insurance partners to promote collaboration pertaining to ongoing skilled needs of the members.
- Organize and prioritize daily work by reviewing the managed care lists, facility census activity, and coordinating with other members of the case management department and insurers.
- Complete documentation as required.
- Ability to complete necessary work in a timely manner to ensure compliance with insurers' deadlines and contractual obligations.
- Review facility census activity and communicate with the facility teams as needed to ensure members on skilled caseload are tracked and managed appropriately.
- Provides support to the facilities, to include managing the continued stay authorization process and verifying that skilled authorizations are obtained for all SNF skilled dates of service.
- Completes clerical duties to include e-faxing, phone calls, uploading of authorization determinations to PCC, reviewing medical record/therapy documentation, and file compilation to accomplish goals of the case management department.
- Gathers information from the electronic medical record and facility IDTs to complete concurrent reviews.
- Ability to work independently and exercise sound judgment in interactions with providers, payers, and facilities.
- Must be able to communicate effectively with, and promote cooperation and collaboration between individuals including providers, payers, facility IDT, and other members of the case management team.
- Must have excellent time management skills to develop organized work processes in a high-volume environment with rapidly changing priorities.
- Intermediate computer skills.
- Ability to relate positively, effectively, and appropriately with providers, facility staff, and professional colleagues.
- Communicate with facility staff, providers, facility financial services, and third-party payers regarding plans of care and status of skilled authorizations and services.
- Performs utilization review activities to ensure delivery of resident appropriate, timely and cost-effective care.
- Monitor resident's statuses and communicate with facility IDT and insurance partners timely and appropriately to convey change in condition/needs that may warrant ongoing skilled care.
Education and/or Experience: Bachelor's Degree in Nursing or Business Administration preferred. Registered Nurse (RN) license preferred. Licensed (LVN or LPN) nurse, or licensed therapist (physical/occupational/speech therapist) acceptable. Two (2) year nursing clinical, managed care insurance, therapist clinical, or case management experience preferred. Knowledge of Medicare, Managed Care, and Medicaid programs and benefits. PCC and Net Health knowledge.
Certificates, Licenses, Registrations: Valid LVN/LPN License or Valid RN License in the state you are working. Will consider candidates with Valid PT, OT, or ST License in the state you are working. Certificate as a certified case manager (CCM) is a plus. Must maintain all required continued education/licensing. Must remain in good standing with the Department of Public Health; License and Certification Division at all times.
