Regional Case Manager Registered Nurse

Medilodge; Grand Rapids (MI); On-site; USD 75,000 - 110,000; Full time

Benefits offered by this job

Affordable Medical, Dental, and Vision

Benefits Concierge

Pet Insurance Options

Tuition Reimbursement

Student Loan Repayment Program

Company Paid Life Insurance

Paid Vacation & Sick Time

401k with Company Match

HSA & FSA

Unlimited Referral Bonuses

Job summary

MediLodge of Grand Rapids seeks a Regional Case Manager (RN) to oversee managed care patients across facilities. The role focuses on maintaining caseloads, reviewing clinical records, negotiating rates, and coordinating with regional and corporate teams to ensure compliant, efficient care delivery.

Qualified candidates have RN credentials, 5+ years in long-term care managed care, and familiarity with MDS, Medicaid, and Medicare processes.

Qualifications

• Registered Nurse preferred.
• Five years of long-term care managed care experience; MDS background preferred.

Responsibilities

• Review all managed care contracts for their facilities.
• Negotiate rates, levels and exclusions with managed care organizations.
• Obtain authorization and re-authorization for new managed care patients.
• Train facility staff on pre-admission case management processes.
• Collaborate with Sales, Marketing, Business Office, Therapy and Clinical teams.

Skills

Case management

Long-term care experience

Medicaid & Medicare knowledge

MDS familiarity

Organizational skills

Communication skills

Education

RN preferred

Tools

Excel

Microsoft Word

Job description

MediLodge of Grand Rapids - SNF
2000 Leonard St NE
Grand Rapids, MI 49505, USA

Description

Regional Case Manager (RCM) Registered Nurse (RN)

Are you ready to reset your case management career with a dynamic and growing healthcare company? If you're ready for the challenge,YOUcould be the right fit for this position! Prestige Healthcare is a leading provider of skilled nursing and rehabilitation services. We are seeking a dynamic remote Regional Case Manager who has a strong work ethic, exceptional organization skills, pays attention to detail, and enjoys working in a fast-paced environment to join our team!

• Are you a Registered Nurse with exceptional Case Management experience in long-term care?
• Do you consider yourself an expert in Medicaid, Medicare, and MDS?
• Are you looking for a new challenge and a supportive corporate team?

What Benefits Do We Offer You?We understand that our employees work best when they are healthy, happy, and excited about the here and now, as well as the future. For that reason, we offer a wide range of benefits with your well-being in mind, including:

• Affordable Medical, Dental, and Vision Benefits for You & Your Family
• Employee Benefits Concierge - to Guide You in Maximizing Your Benefits
• Three Pet Insurance Options for your Furry Friend
• Tuition Reimbursement
• Student Loan Repayment Program
• Company Paid Life Insurance
• Paid Vacation Days with Rollover Option and Sick Time
• 401k Retirement with Company Match
• Health Savings Account (HSA) and Flexible Spending Account (FSA)
• Unlimited Referral Bonuses and more!

Summary: The Regional Case Manager is responsible for maintenance of a case load of managed care patients and to review clinical records, negotiate rates, exclusions, and length of stay with case managers from managed care organizations. Provides the link between managed care related regional and corporate initiates and partners with Operations, Marketing, Clinical Reimbursement, Therapy, Finance and Billing to implement managed care processes and procedures according to company policies and procedures.

Qualifications:

Education:

• Registered Nurse preferred.

Experience:

• Five years of experience with long-term care related managed care. A background in MDS is preferred.

Job Functions:

• Review all managed care contracts executed for their facilities.
• Understand and communicate the needs of the regional and center staff to the Director of Managed Care to assure consistency in direction and execution of managed care.
• Establish relationships with managed care organization’s Case Managers, specific to region.
• Review clinical record, identify and negotiate higher levels and exclusions, where applicable.
• Negotiate all rates, levels and one-time contracts for defined health centers managed care patients.
• Obtain authorization, re-authorization and notifications for all new managed care patients for health center.
• Complete all required documentation associated with rates, levels of care, cuts and exhausts as required by managed care organization.
• Complete and maintain Case Manager Log on a daily basis.
• Communicate with centers the needed documentation for continued stay and patient cuts.
• Participate with facilities weekly (telephonically or center visit) to review managed care patients.
• Participate in monthly triple check meetings for final review of UB statements and billing of negotiated exclusions.
• Train facility staff on pre-admission case management process specific to their regional contracts.
• Work collaboratively with Sales and Marketing, Business Office, Therapy, and Clinical team to provide appropriate services needed within the definition of the managed care contract.
• Assist with any audits by the managed care organizations in conjunction with Medical Review.
• Performs other duties as assigned.

Knowledge/Skills/Abilities:

• Ability to use personal computer and application software such as Excel and Microsoft Word.

Functional speech, vision and hearing.

Ability to communicate professionally and effectively with referral sources at all levels of the organization both orally and in written form.

Strong organizational skills. Ability to organize and prioritize.

Able to work independently, self-motivated and goal oriented. Demonstrates self-confidence.

Equal Opportunity Employer
This employer is required to notify all applicants of their rights pursuant to federal employment laws.For further information, please review the Know Your Rights notice from the Department of Labor.