Utilization Management/Case Manager

Job Summary

As a Utilization Management/Case Manager at Accolade Healthcare, you will be responsible for coordinating the continuum of care for patients, with a strong focus on insurance authorizations, case management, and discharge planning. This role is vital to ensure that services are covered, appropriately authorized, and effectively managed to achieve optimal patient and financial outcomes.

Pay: $75,000-$90,000 annually

Benefits:
• Medical, Dental, Vision and additional other voluntary benefits
• 401k with company match
• Generous Paid Leave Policy
• Daily Pay partner

Responsibilities:

As a Utilization Management/Case Manager, your responsibilities include:
• Coordinate and manage care for a caseload of SNF patients, ensuring timely authorizations and continued stay approvals.
• Collaborate with interdisciplinary care teams, including physicians, therapists, social workers, and payors, to promote seamless transitions and quality care.
• Obtain and manage insurance authorizations for inpatient SNF care, including commercial plans, Medicare Advantage, Medicaid, Workman's Compensation, No-Fault, and Single Case Agreements (SCA).
• Negotiate reimbursement rates for non-contracted payors when necessary.
• Review and respond to denials and discrepancies in authorizations; prepare appeal documentation and participate in QIO or health plan-level appeals as needed.
• Identify patient care needs, assess insurance limitations, and work with the healthcare team to develop appropriate care plans.
• Advocate for patient access to appropriate services while maintaining compliance with insurance guidelines.
• Maintain accurate and up-to-date documentation in accordance with facility, insurance, and regulatory standards.

Skills and Qualifications:

To excel as a Utilization Management/Case Manager, you will need:
• Licensed Registered Nurse (RN) or equivalent clinical credential preferred.
• Minimum 2 years of case management experience, preferably in a SNF, hospital, or managed care setting.
• Strong knowledge of insurance authorization processes, managed care, and appeal strategies.
• Experience with Single Case Agreements, Workman's Comp, and No-Fault contracts.
• Excellent communication, negotiation, and interdisciplinary collaboration skills.
• Proficient in electronic health records and case management software.
• Familiarity with CMS guidelines, QIO processes, and discharge planning protocols.
• Ability to manage a high-volume caseload with a proactive and organized approach.
• Knowledge of Medicare and Medicaid regulations specific to SNFs.

On-site or hybrid work environment depending on facility needs.

Fast-paced, patient-centered setting with frequent interaction with healthcare professionals and insurance representatives.