Case Manager (RN)
Job Posting for Case Manager (RN) at Prestige Healthcare
Summary:
Responsible for maintenance of a case load of managed care patients of several buildings. Responsible to review clinical record, negotiate rates, exclusions and length of stay with case managers from managed care organizations. Provides the link between managed care related regional and corporate initiates. Partners with Operations, Marketing, Clinical Reimbursement, Therapy, Finance and Billing to implement managed care processes and procedures according to Prestige Healthcare’s policies and procedures. Coordinates all training, standardization and monitoring of managed care processes with Director of Managed Care and assures compliance with company policies and procedures. Completes appropriate reports that will measure the implementation of region specific managed care.
Qualifications:
Education:
Responsible for maintenance of a case load of managed care patients of several buildings. Responsible to review clinical record, negotiate rates, exclusions and length of stay with case managers from managed care organizations. Provides the link between managed care related regional and corporate initiates. Partners with Operations, Marketing, Clinical Reimbursement, Therapy, Finance and Billing to implement managed care processes and procedures according to Prestige Healthcare’s policies and procedures. Coordinates all training, standardization and monitoring of managed care processes with Director of Managed Care and assures compliance with company policies and procedures. Completes appropriate reports that will measure the implementation of region specific managed care.
Qualifications:
Education:
- Registered Nurse preferred
- Five years of experience with long-term care related managed care. A background in MDS is preferred.
- Review all managed care contracts executed for their facilities.
- Understand and communicate the needs of the regional and center staff to the Director of Managed Care to assure consistency in direction and execution of managed care.
- Establish relationships with managed care organization’s Case Managers, specific to region.
- Review clinical record, identify and negotiate higher levels and exclusions, where applicable.
- Negotiate all rates, levels and one-time contracts for defined health centers managed care patients.
- Obtain authorization, re-authorization and notifications for all new managed care patients for health center.
- Complete all required documentation associated with rates, levels of care, cuts and exhausts as required by managed care organization.
- Complete and maintain Case Manager Log on a daily basis.
- Communicate with centers the needed documentation for continued stay and patient cuts.
- Participate with facilities weekly (telephonically or center visit) to review managed care patients.
- Participate in monthly triple check meetings for final review of UB statements and billing of negotiated exclusions.
- Train facility staff on pre-admission case management process specific to their regional contracts.
- Work collaboratively with Sales and Marketing, Business Office, Therapy and Clinical team to provide appropriate services needed within the definition of the managed care contract.
- Examine current processes for improvement, compliance, and recommend change in policies and procedures as appropriate. Communicate areas of opportunity to Director of Managed Care.
- Assist with any audits by the managed care organizations in conjunction with Medical Review.
- Home office/facility based position, but traveling is a requirement of the job, based on the needs of area, region and center as directed by the RDO or Director of Case Management. Must be able to travel between centers.
- Performs other duties as assigned and as necessity dictates.
- Ability to use personal computer and application software such as Excel and Microsoft Word.
- Functional speech, vision and hearing.
- Ability to communicate professionally and effectively with referral sources at all levels of the organization both orally and in written form.
- Strong organizational skills. Ability to organize and prioritize.
- Able to work independently, self-motivated and goal oriented. Demonstrates self-confidence.
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