Full-Time Exempt
Job Summary:
The Case Manager is responsible for all case management activities assigned. This includes case management and utilization management. The Case Manager provides concise management of patients’ hospitalization from pre-admission through discharge in the areas of patient care, fiscal management, and Payor/referral satisfaction. The Case Manager is responsible for conducting Discharge Planning Evaluations, performing discharge planning to ensure patients and their families receive maximum benefits, and awareness of community and government agencies. This position requires the use of communication skills, the ability to perform management operations directly related to administrative goals and policies, to provide regular and direct assistance to executives, to perform work and special assignments under only very general supervision, and to continuously develop department operations toward efficiency and effectiveness.
Duties and Responsibilities (includes, but is not limited to the following):
- Obtain prior authorizations for procedures, services, and hospital admissions from insurance providers.
- Prepare and submit clinical documentation (clinicals) to support medical necessity and secure insurance approvals.
- Communicate regularly with insurance companies and third-party payers to verify coverage, obtain approvals, and resolve issues.
- Appeal and overturn insurance denials by gathering supporting documentation, writing appeal letters, and collaborating with providers.
- Coordinate with utilization review (UR) nurses and internal clinical teams to ensure compliance with payer requirements and standards of care.
- Track and document all communication, authorizations, denials, and appeals in the electronic medical record (EMR) or case management system.
- Monitor patient progress and collaborate with the care team to support discharge planning and continuity of care.
- Stay current on payer guidelines, authorization processes, and regulatory requirements.
- Admits new clients by reviewing records and applications; conducting orientations.
- Determines clients’ requirements by completing intake interviews; determining need for therapeutic medical, psycho-social, and psychiatric evaluations; reviewing therapist evaluations, treatment objectives, and plans.
- Establishes treatment programs by setting schedules and routines; coordinating services being provided; arranging resources, including transportation and escort.
- Monitors cases by verifying clients’ attendance; observing and evaluating treatments and responses; advocating for needed services and entitlements; obtaining additional resources; intervening in crises; providing personal support.
- Maintains clients’ records by reviewing case notes; logging events and progress.
- Communicates clients’ progress by conducting weekly interdisciplinary meetings and evaluations; disseminating results and obstacles to therapeutic team and family; identifying treatment influences.
- Prepares clients’ discharge by reviewing and amplifying discharge plans; coordinating discharge and post-discharge requirements; orienting and training family members; providing resources.
- Meets budget by monitoring expenses; implementing cost-saving actions.
- Prepares reports by collecting, analyzing, and summarizing treatment and results data and trends; compiling statistics; completing grant and subsidy applications.
Education, Licensure and/or Certifications
- Current California LVN or RN license
- Three (3) years of work experience in a medical case management setting preferred.
Experience and Qualifications
Good organizational and liaison capabilities with well-developed written and verbal communication abilities are required. Well demonstrated public relations skills with a cooperative and assertive attitude. Working knowledge of the insurance industry is required.
- Have an understanding of the commercial insurance appeal process.
- Have a working knowledge of billing ad reimbursement and letter of agreement.
- Be knowledgeable regarding pre-certification and concurrent review process.
- Must have clear and concise professional language in the preparation of up to date clinical reports representing the patient’s total condition and treatment plan.
- Have working knowledge of Federal and State Regulatory Compliance.
- Have a good working knowledge and ability to facilitate interdisciplinary team conference identifying clinical challenges and outstanding issues.
- Ability to discharge patients successfully without adverse health consequences with all needs identified.
Supervisory
- Case Management personnel
Other Skills and Abilities
- Maintains confidentiality of patients at all times
- Sensitivity to and willingness to interact with persons of various social, cultural, economic and educational backgrounds.
- Proficiency with Microsoft Office applications including Outlook, Word, Excel and PowerPoint.
- Strong organizational skills with ability to prioritize projects, work relatively independently, manage multiple tasks, and meet deadlines.
- Strong written and verbal communication skills.
- Ability to work independently and as part of a team.
- Good judgment, problem solving and decision-making skills.
- Demonstrated commitment to working collaboratively as well as possessing the skills to lead, influence, and motivate others.
- Ability to work in a fast-paced, expanding organization.
It is the policy of Sonoma Specialty Hospital not to discriminate against any applicant for employment, or any employee because of age, color, sex, disability, national origin, race, religion, or veteran status.
