Clinical Case Manager

Guided-Care; United States; Remote; USD 70,000 - 90,000; Full time

Job summary

Guided-Care is seeking a Clinical Case Manager to oversee patient caseloads, coordinate insurance authorizations, and manage AR processes. You will participate in UR meetings and maintain high-quality client communication while upholding GUIDE principles.

Remote work is supported; nursing or therapy licensure is preferred along with 5+ years in healthcare. Strong organizational and collaboration skills are essential for success in a fast-paced environment.

Qualifications

• 5+ years of experience in a healthcare environment.
• Ideal candidate is a licensed nurse (RN, LPN) or licensed therapist (OT, OTA, PT, PTA, SLP).
• Skilled Nursing, LTACH, Hospital experience preferred.
• Independent and self-motivated with strong research and organizational skills.
• Thrives in a fast-paced, high-pressure environment.
• Strong time management with a proven ability to meet deadlines.
• Solid collaborative skills with team and clients.
• Ability to work remotely and autonomously.
• Demonstrate discretion, sensitivity, and ability to maintain confidentiality.
• Proficient in Microsoft Office; able to learn new programs; comfortable with Zoom/Teams.

Responsibilities

• Maintain a skilled caseload of 77 patients per day or as established by Senior Leadership.
• Ensure increased length of stay, higher reimbursement, and proper authorization coverage.
• Review AR logs and send them to clients on the first business day of the month for previous month.
• Attend UR meetings and participate in 1:1 with the Supervisor monthly.
• Remit on due date with all required forms and complete clinical packets for NRD to insurance.
• Follow up with insurance for NRD determinations within 72 business hours.
• Coordinate/submit all appeal requests to appeals team and sometimes QIO/Health plan directly.
• Review and obtain carve-outs as outlined in insurance contracts.
• Maintain Guided Care program accuracy and client caseload details.
• Respond to client emails and requests by end of business day.
• Maintain high level of customer service and professionalism; communicate respectfully.
• Collaborate with colleagues and handle additional cases during downtime.
• Uphold and practice company principles (GUIDE) in all work interactions.

Skills

Healthcare experience

Independent and self-motivated

Time management

Collaborative skills

Research and organizational skills

Remote work capability

Customer service orientation

Effective communication

Ability to meet deadlines

Education

RN/LPN license or licensed therapist license

Tools

Microsoft Office

Video conferencing (Zoom/Teams)

Job description

Position Overview: Clinical Case Manager

The Clinical Case Manager is responsible for ensuring the increased length of stay, higher levels of reimbursement, medication carve-outs, and authorization coverage throughout patient stays. The Clinical Case Manager reports to the Supervisor of Clinical Case Management.

Key Results Area

Puts forth best efforts to learn and understand full training provided upon onboarding.

Maintain a skilled caseload of 77 patients per day or as established by Senior Leadership, post the 90-day probationary period.

Maintains an average length of stay is 22+ for assigned clients.

Maintains no more than 10 missing levels post 10 days of admission, with the goal to average 0.

Maintains no more than 5 errors across caseload per 30 days on average.

Reviews AR logs for accuracy and sends them out to clients on the first business day of the month for the previous month for all assigned clients.

Attend all UR meetings per assignment to communicate level requirements and capture the nuances of patient care being provided by clients.

Participate in 1:1 meeting with the Supervisor monthly.

Remits on the due date, cover page, insurance required form, and complete clinical packet at each NRD to insurance.

Follow up with insurance for determination on all NRDs within 72 business hours, to ensure the client does not incur provider liable days.

Coordinate/submit all appeal requests to the appeals team, at times submitting appeals to the QIO/ Health plan directly to meet deadlines.

Review and obtain carve-outs as outlined in the specified insurance contract or policy.

Maintain the Guided Care program with patient details as required and skilled listing, to ensure the accuracy of the current caseload.

Respond to client emails and requests by the end of business day.

Maintain a high level of customer service and professionalism in all methods of communication.

Communicates respectfully with colleagues and leadership.

Collaborates with colleagues, helping and handling additional cases during downtime or a lull in individual caseload.

Other duties as assigned.

Evaluate and assess personal performance on a routine basis.

Agree to uphold and practice company principles (GUIDE) in all work-related interactions.

Requirements

• 5+ years of experience in a healthcare environment.
• Ideal candidate is a licensed nurse (RN, LPN) or licensed therapist (OT, OTA, PT, PTA, SLP)
• Skilled Nursing, LTACH, Hospital experience preferred.
• Independent and self-motivated.
• Innovative and detail-oriented professional with strong research and organizational skills.
• Thrives in a fast-paced, high-pressure environment.
• Strong time management with a proven ability to meet deadlines.
• Solid collaborative skills with team and clients.
• Ability to work remotely and autonomously.
• Ability to establish and maintain positive relationships.
• Ability to communicate and exchange information and ideas so others will understand.
• Demonstrate discretion, sensitivity, and ability to maintain confidentiality.
• Quality camera to be used when joining internal and client meetings scheduled via Zoom, Teams, or other video meeting platforms. When participating focus on the matter at hand. Refrains from actively performing other duties even if work-related.
• Joins scheduled client meetings timely, best practice 3 minutes before the meeting time, to ensure the best self and company representation.
• Microsoft Office proficiency, with the aptitude to learn new programs.