Regional Case Manager

Are you looking for your new career? We are now hiring a Regional Case Manager to be the newest member of our awesome team!

Salary Range: $115-125k

The Regional Case Manager is responsible to support the facility Case manager and IDT to ensure the collaborative process of evaluation, planning, facilitation and advocacy for options and services to meet the patient’s health needs through communication and available resources to promote quality and cost-effective outcomes. The Case Manager ensures the Interdisciplinary Team implements agreed-upon, necessary services as outlined in the patient plan of care subject to contract terms and case negotiations in order to minimize over-utilization or under-utilization of services and associated unreimbursed claims.

He/she is assigned to oversee the Case Management Operations across their regional assignment. This may include assuming the roles of facility Case Manager for a period of time when need necessitates. This Dedicated Case Manager performs responsibilities at the site of service and/or performs responsibilities at an off-site location.

He/she identifies opportunities for quality and performance improvement and communicates to supervisor and/or Administrator. The Regional Case Manager performs to establish productivity metrics which reflect the Case Manager’s effectiveness and efficiencies in carrying out responsibilities.

RESPONSIBILITIES/ACCOUNTABILITIES:

• Based on standard operating procedures, verifies and communicates to payor from patient Pre-Admission through Concurrent Review using standard and plan review forms to justify clinical necessity according to payor review schedule. Ensures documentation is timely, accurate and complete in PCC and field file.
• Reviews Pre-Admission Review (PAR) and IRM Pre-Authorization assessment to identify costly treatments, supplies or services.
• Negotiates for appropriate continuation of length of stay or extension of services and appropriate Level of Care (what is covered/what is not covered) and associated rates.
• Facilitates obtaining payor authorization for recommended treatments, procedures, supplies, equipment and medications and all exclusions
• Reviews Admission orders on all managed care patients for skilled need. If necessary, re-negotiates Length of Service and Level of Care.
• Communicates contract terms for patient’s stay to Interdisciplinary Team, e.g. Level of Care, Length of Service, Utilization of Services, Inclusions and Exclusions, Revenue Per Day, Network Providers, Rehab Treatments
• Actively monitors patient case throughout stay to ensure utilization of services are in accordance with plan of care and minimize financial risk to patient and center.
• Acts as resource for IDT to identify alternate treatment options
• Liaises with appropriate staff to gain or provide information, e.g. CRC, Unit Manager, Social Worker, Business Office, Rehab Program Manager.
• Reviews rehab software Documentation and clearly document current clinical and discharge planning information sent to payer and maintain in field file
• Actively participates in Utilization Meetings
• Alerts appropriate staff and vendors of non-covered services.
• Alerts appropriate staff when duplicate services are ordered.
• Educate staff regarding terms of contracts.
• Identifies overuse of resources such as rehabilitation therapy, diagnostic studies, non- formulary medications and medical supplies
• Alerts Center Designee to last covered day of service. Requests Notice of Non- Coverage be delivered to patient/family for signature with copy of notification in Center Financial File.
• Assists Center in responding to denial of continued skilled services as determined through intermediaries or Health Plan criteria. Writes appeals to insurance plans as needed.
• Prepares patient case for discharge/transition by ensuring network providers are known and securing all appropriate authorizations for a safe, coordinated discharge for patient/caregiver.
• Communicates to Health Plan any patient/family risk factors as it relates to barriers to a timely discharge.
• Consults Social Worker immediately for all social, customer/family problems that are identified as barriers to a timely, appropriate discharge.
• Maintains comprehensive case management records on all customers that reflect authorizations, extensions, levels of care, and dates of service and rates approved by the payer to include name, phone and date of payer case manager’s authorization.
• Manages relationships with 3^rd party payors ensuring timely
• Identifies service delivery and process improvements and communicates to
• For Dedicated Case Manager’s, additional support may be provided directly to patient/family and/or caregiver with respect to:
  1. Discharge Planning: Communicates anticipated skilled discharge date and supports staff in development of discharge plan.
  2. Educational Support: May participate in Family Care Meetings and may provide additional support to patient/caregivers as needed.
  3. Non-Covered Services: Create and distribute Adverse Determination and/or 48 Hour Notification Letter to patient.

Compliance:

1. Complies with applicable legal requirements, standards, policies and procedures including but not limited to those within the Compliance and Ethics Program, Standard/Code of Conduct, Federal False Claims Act and HIPAA.
2. Participates in required orientation and training
3. Promptly reports concerns and suspected incidences of non-compliance to supervisor, Compliance Liaison or to the Compliance Officer via the Integrity
4. Cooperates with monitoring and audit functions and
5. Participates, as requested, in quality assurance and process improvement

Educational requirements: 

1. Active LVN or RN license
2. Five years of recent clinical experience Prior experience in utilization review, case management or discharge planning required.
3. Prior experience using evidence-based clinical decision support criteria
4. Experience in rehabilitation nursing, acute care and/or the insurance field Two years full time experience in utilization review which includes service to short/long term facility-based clients preferred.
5. Valid driver’s license and automobile with valid insurance
6. Advanced knowledge of third-party reimbursement, insurance coverage and contract
7. This position requires that the employee is able to read, write, speak and understand the spoken English language to ensure the safety and wellbeing of our patients and visitors at the work site when responding to their medical and physical needs.
8. Must provide verification of TST (tuberculin skin test) as required by state law and in accordance with Company TSTs will be administered at the work site if required.

What makes us special?

• Competitive Wages!
• Great benefits – Medical, dental, and vision coverage
• Growth Opportunities
• Continuing Education / Training Opportunities

Are you ready to contribute to a team, committed to excellent customer service and dedicated to each individual’s unique talent?

Equal Opportunity Employer

All qualified applicants will be considered for employment without regard to race, color, religion, sex, gender identity, sexual orientation, age, national origin, veteran or disability status, or any other characteristic protected by law.

Pay Transparency Statement

Compensation for roles varies depending on a wide array of factors including but not limited to the location, role, skill set and level of experience. As required by state or local law, we provide a reasonable pay scale to include the hourly or salary range that we reasonably expect to pay for roles, as stated above.

Salary : $115,000 - $125,000