Case Manager

Skilled Nursing Facility located in Queens County is seeking an experienced Case Manager. The Case Manager coordinates financial coverage and insurance authorizations for all residents to ensure a viable payer source for each day of their stay. This position serves as the primary liaison between clinical teams, families, and payers to support seamless reimbursement, continuity of care, and timely Medicaid eligibility processing. The case manager will report to the Administrator and Director of Financial Services.

Essential Duties and Responsibilities

· Obtain and follow up on all managed care authorizations to ensure coverage is active at all times.

· Secure new authorizations when a resident changes payer source (e.g., Medicare exhaust, level of care change).

· Request and verify authorizations appropriate to the resident’s level of care (Ventilator, Skilled, or Custodial).

· Review all authorizations for accuracy; initiate corrections immediately when discrepancies are found.

· Submit and track appeals for authorization denials.

· Maintain an Authorization Tracker (UR) and send weekly updates to the team.

· Enter and update authorization codes in the EMR when obtained, revised, or when payer sources change.

· Follow the escalation process for obtaining and correcting authorizations as needed.

· Works with Facility AR Specialist when asked

· Meet with families of potential long-term residents and follow up as needed via phone or email.

· Maintain knowledge of residents’ income sources (e.g., SSA, pension, IRA distributions) and explain Medicaid eligibility requirements clearly to families.

· Explain NAMI (Net Available Monthly Income) to residents and families, distinguishing between MLTC NAMI and traditional Nursing Home Medicaid NAMI.

· Gather all documents listed on the required Medicaid documentation checklist, review for completeness, and follow up on inconsistencies.

· Screen all new admissions promptly for potential Nursing Home Medicaid eligibility and explain applicable co-payments starting on day 21, if relevant.

· Email details of each patient’s eligibility status, plan of stay/rehab, and maintain follow-up in the same email thread until all required documents are received and the packet is ready for Medicaid submission.

· Prepare and submit MAP-2159i (Long-Term Placement) forms to the appropriate MLTCs, copying or forwarding to Rehab for follow-up with case managers to obtain signed forms.

· Contact residents, families, or representatives regarding plan changes.

· Submit requests to new payers and confirm changes with the Business Office Manager.

· Communicate plan changes to billing, administration, and relevant team members.

· Follows up with both old and new plans to validate successful transfers.

· Receive, review, and respond to all insurance correspondence (mail, phone calls, fax, or email). Ensure timely communication and proper documentation of all payer-related updates.

· Notify the appropriate staff when changes in authorization or level of care occur.

· Seek guidance from the Administrator or Supervisor when questions arise outside the scope of daily operations.

POSITION QUALIFICATIONS:

Ø Education: High School Diploma required; Associate’s or a Bachelor’s degree in Healthcare Administration, Nursing, or related field preferred.

Ø Experience: Minimum two years of experience in healthcare case management, billing, or utilization review, preferably in a skilled nursing or long-term care setting.

Skills:

• Knowledge of Medicaid and managed care processes

• Proficiency in EMR and Microsoft Office

• Strong organizational and follow-up skills

• Effective written and verbal communication

• Ability to multitask and meet tight deadlines

• Familiarity with MAP-2159i and Medicaid documentation requirements

EOE Statement:

WE ARE AN EQUAL OPPORTUNITY EMPLOYER. Applicants and employees are considered for positions and are evaluated without regard to mental or physical disability, race, color, religion, gender, national origin, age, genetic information, military or veteran status, sexual orientation, marital status or any other protected Federal, State/Province or Local status unrelated to the performance of the work involved.