Case Manager

Grand Terrace

Come join our team and start making a difference!

Admissions and Authorization Management


* Review referrals and clinical documentation to determine appropriateness for SNF admission.


* Coordinate pre-admission assessments and payer eligibility verification.


* 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 facilitate and streamline care transition to SNF.


* Ensure timely communication with payers regarding clinical updates and authorization requests.

Clinical Reimbursement and Care Coordination


* 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.


* Section GG and PDPM Leadership
+ Serve as the clinical champion and facilitator 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 that reflects true patient care needs.

Utilization and Length of Stay Management


* 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.


* Utilization Defense: Utilize objective clinical and functional data to build robust clinical justifications for continued skilled stay, effectively communicating functional deficits to managed care payers during concurrent reviews.


* Peer-to-Peer and Appeals Managements: Must have the clinical acumen to assist prepping the Medical Director for peer-to-peer reviews and execute expedited appeals when a managed care organization issues an inappropriate discharge.

Discharge Planning and Care Transitions


* Coordinate with IDT on individualized discharge plans upon admission.


* Coordinate 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.

Regu...