An equal opportunity employer. All qualified applicants will receive consideration for employment and will not be discriminated against on the basis of disability, race, ethnicity, gender, religion, or otherwise. Minorities, veterans, and individuals with disabilities are encouraged to apply.
POSITION PURPOSE: :
Promote quality and cost effective interventions and outcomes or facility(s) managed care population. Responsible for the daily duties and outcomes for the case management functions in assigned SNFs.
ESSENTIAL FUNCTIONS OF POSITION::
* Follow Case Management Processes from intake to discharge. (to include, but not limited to: Authorization, Admission processes, PPS/UR Processes, MMP Policy, Skill in Place process, NOMNC/DC planning compliance, appeals process, Concurrent reviews, notifying insurance Case Manager of changes, maximizing reimbursement, etc as defined below)
* Maintains organized correspondence system with sufficient clinical information from all relevant sources and its documentation regarding case management activities and/or services. Maintain updated tracking log of all members in case management program assisting in outcome measurement.
* Performs effective/timely concurrent reviews according to established guidelines, expectations, and timeframes utilizing clinical assessment skills/knowledge. Accurately documents in the Case Management program specific activities and interventions that lead to accomplishing goals/outcomes.
* Actively participates in SNF meetings and keeps IDT appraised of Case Management activities (in-person or via conference call). Attend weekly/bi-weekly Case Management UR Outcomes calls with supervisor as scheduled. Prioritize facility visits according to case load and acuity needs. Drive Length of Stay (LOS) Goals and outcomes, drive the DC process, Issue NOMNCs timely with all required info.
* Build and Maintain effective communication skills and a positive relationship with the MCO CM’s for an overall goal of increased managed care census, improved LOS metrics, and increased patient/payor satisfaction outcomes.
* Ensure services delivered are authorized. Understand contract reimbursement and authorized services upon admission and ongoing. Negotiate Authorized services during stay to cover additional needed services (as needed for the patients stay)
* Provide out of network (OON) Letter of Agreement (LOA/SCA) support to authorization staff.
* Support Growth and Development of new programs. Provide Education to SNFs as needed to improve knowledge of expected outcomes and improve supporting documentation.
* Works collaboratively with others to problem solve. Involve Supervisor as needed.
* Other duties as assigned.
EDUCATION / REQUIREMENTS: :
* RN or LVN with a Texas License. Long Term Care experience preferred.
* Broad knowledge base of insurance and managed care processes.
* Employee should be detail oriented, have excellent customer service skills, a working knowledge of electronic health records, be a self-starter, and must have excellent time management skills.
* Must be able to travel with some overnight stays.