Regional Case Manager at Lynbrook

Job Description

We are currently conducting a search for a Regional Case Manager to join our growing team for the Long Island, NY area. To be successful in this role you will need to be an experienced clinician with a working knowledge of successful case management in long term care market. You will need to be a compassionate, energetic and focused nurse with the ability to accurately assess needs and coordinate services. You must have the proven ability to successfully coordinate the care and follow up of a full case load while ensuring the best outcomes.


Job Title: Case Manager/Regional Case Manager
Department: Nursing/Case Management
Reports To: Coordinator of Case Management


Position Summary: Responsible forquality, cost effective services and care utilizing a collaborative process that coordinates, monitors and evaluates services provided to all managed care/commercial insurance patients that are admitted to the facility.


Essential Duties and Responsibilities:

• Participate in team based meetings to assess and plan the managed care patient goals and interventions.
• Through patient discharge, monitor and evaluated interventions and outcomes
• Facilitate team management of the managed care patient, i.e. continuing stay,resource management and discharge planning.
• Provide current, accurate and complete clinical information to payor to justify continuation of stay
• Be familiar with insurance coverage and contract requirements/maintain a current and comprehensive knowledge of third party payors, insurance reimbursement and the appeal and denial process
• Negotiate for appropriate level of care and exclusions to contract
• Assist/instruct facility on how to respond to denial of payment or authorization with clinical information to substantiate continued coverage
• Facilitate/assist facility in obtaining prior authorization for transportation, treatments, procedures, supplies or excluded medications
• Review pre-admission assessments when asked to identify high cost treatments, supplies, medications or services and the corresponding insurance coverage/level/rates/exclusions
• Clearly communicate contract inclusions and exclusions to the facility team as necessary
• Facilitate team management of the managed care patient, i.e. continuing stay,esource management, discharge planning
• Educate facility on their responsibilities to case management as outlined in policy and procedures
• Facilitate/assist facility in appeal and denial process
• Educate facility staff in cost containment and covered services
• Identify overuse of resources such as rehabilitation therapy, diagnostic studies,non-formulary medication and medical supplies
• Clearly document all concurrent review and discharge planning information sent to payor
• Advise facility/billing of change in payor
• Advise billing of billable exclusion
• Submit utilization data/information/reports as requested by Regional Case Manager
• Review month Managed Care Evaluations and submit report addressing profit and loss
• Seeks memberships and networking opportunities to promote facilities ownedby National Health Care Associates
• Complies with all National Health Care policy and procedures as they relate to case management and personnel
• Perform other duties as requested
  
  
  Education and Experience: Graduate of an accredited LPN/RN nursing program. Recent clinical nursing experience required. Prior experience in utilization review, case management or discharge planning. Experience/knowledge of Medicare, Milliman and Interqual guidelines highly desirable. Experience in rehabilitation, acute care and insurance field preferred.
  
  
  Computer Skills: Proficiency required
  
  
  

Job Requirements

 
Country: USA, State: New York, City: Lynbrook, Company: NATIONAL HEALTH CARE ASSOCIATES.