Clinical Case Manager / MDS

Resorts at Pooler; United States; On-site; USD 65,000 - 90,000; Full time

Benefits offered by this job

Restaurant d'entreprise

Indemnités de stage/alternance

Job summary

Resorts at Pooler is seeking a Clinical Case Manager - Utilization Review to coordinate insurance authorizations, care plans, and billing data.

You will interface with admissions, nursing, therapy, social work, and the billing department to ensure accurate documentation and timely reimbursements.

The role emphasizes organized records, proactive communication with payers, and rigorous tracking of authorizations and reviews to support residents' care and the facility's finances.

Qualifications

• Experience managing schedules and data across multiple cases.
• Proficient with EMR and spreadsheet tools.
• Strong communication with payers and care teams.
• Background in long-term care or skilled nursing.

Responsibilities

• Obtain and track initial and ongoing authorizations with payers.
• Collaborate with care team to align plans with insurance requirements.
• Verify coverage and resolve denials with the billing office.
• Maintain organized digital files and logs for authorizations and notes.

Skills

Org skills

Excel/Sheets

Communication

Clinical knowledge

Tools

EMR systems

Microsoft Excel

Job description

Job Title: Clinical Case Manager - Utilization Review

Role Overview:

We are seeking a highly organized and detail-oriented Case Manager/MDS to manage the intersection of clinical care and financial reimbursement. This role is primarily focused on managing insurance authorizations, coordinating with the interdisciplinary care team, and ensuring that our billing office has the precise information needed for seamless revenue cycles.

Key Responsibilities

• Insurance Authorization Management:

  • Work with admissions department to proactively obtain and track initial and ongoing authorizations for all insurance plan.

  • Monitor "next review dates" and submit timely clinical updates to payers to prevent denials.

  • Serve as the primary point of contact for insurance case managers.

• Care Team Coordination:

  • Participate in weekly meetings with nursing, therapy, and social work to ensure plans of care align with insurance requirements.

  • Attain necessary clinical documentation from team to track progress and submit to plans as required.

• Billing & Financial Liaison:

  • Work closely with the Business Office Manager and billing department to verify coverage and resolve technical denials.

  • Maintain a systematic log of all authorizations, appeals, and clinical reviews to ensure the billing office has real-time data.

• Administrative Oversight:

  • Manage a high volume of digital files, ensuring all physician orders and therapy notes are organized and accessible.

  • Maintain meticulous records of phone conversations and email correspondence with payers.

  • Track all necessary information on each case for timely and efficient billing.

Required Qualifications & Skills

• Systematic Organization: You must have a proven ability to manage multiple deadlines and track complex data points without items falling through the cracks.

• Technical Proficiency: Computer skills are essential, including experience with Electronic Medical Records (EMR) and Microsoft Excel/Google Sheets.

• Professional Communication: Excellent phone etiquette and the ability to advocate firmly but professionally with insurance companies.

• Clinical Knowledge: A background in long-term care, skilled nursing setting is required. A Nurse or a Social Worker (LSW) with heavy experience in utilization review and medical terminology is preferred.

Why You’ll Excel in This Role

You enjoy "putting the puzzle pieces together." You find satisfaction in keeping a clean, organized digital workspace and ensuring that the hard work of the clinical team is accurately reflected in the facility’s financial health as you advocate for your residents.