Overview

Responsibilities

KEY RESPONSIBILITIES:
1. Facilitates daily care coordination meetings to ensure care resources are aligned with benefits and
patient needs
2. Participates and facilitates Engage/72 HR Admission meeting. Ensures coordination as part of the
care management system
3. Responsible for the coordination of the restorative nursing program including integration of the
activity department
4. Ensures timely communication with the patient/family regarding changes in condition and discharge
planning
5. Responsible for the ongoing communication to all insurance case managers
6. Manages all initial reviews, interim reviews and discharge reviews (Managed Care
authorizations/reauthorizations).
7. Collaborates with clinical team in the development and execution of care plan
8. Ensures timely facilitation of patient care rounds/conferences to review treatment plan and identify
discharge and post discharge needs
9. Ensures utilization of company tools/resources related to care management - e.g. Dart
Chart/Managed Care Log
10. Coordinates discharge planning and post-discharge communication - home health/DME, etc.
11. Determines need for non-coverage notification and is responsible for issuance of the beneficiary
notices as well as communication with patients/families/payers
12. Monitors Quality Measures along with other members of care coordination team
13. Serves as a skilled care documentation specialist ensuring that Medicare and Managed care
regulatory guidelines are completed accurately and timely (i.e. certifications, denial letters, skilled
documentation, coverage criteria, etc.)
14. Reviews Additional Documentation Requests (ADRs) with Health Information Management
Coordinator (HIMC) to ensure all documents are available and meet the request

Qualifications

BACKGROUND QUALIFICATIONS:
1. Degree in nursing, therapy or other related clinical field (i.e. social services), must hold a current
license in respective field.
2. Knowledge of healthcare reimbursement, utilization management, and discharge planning.
3. Experience providing strategic leadership, managing teams and leading projects required.
4. Ability to formulate and implement short and long term strategic plans
5. Strong verbal, written and interpersonal skills.
6. Must have proven ability to lead a team to achieve desired outcomes of team
7. Strong communication and organizational skills required
8. Must have knowledge of PDPM requirements of insurers
9. Must have understanding of regulatory requirements
10. Previous case management experience preferred