Job Description
Paradigm Healthcare LLC is Hiring a Licensed Nurse Case Manager In keeping with the organization's goals, the Case Manager/ Prior Authorization Liaison- Managed Care Department, is responsible for providing comprehensive telephonic case management, insurance verification, and authorization services for our skilled nursing facilities (SNFs). This role supports the managed care continuum from referral and admission through ongoing utilization review, discharge planning, and continuation of care.
The position partners closely with Managed Care Organizations (MCOs), referral sources, and facility leadership to promote managed care census growth, ensure appropriate levels of care, maximize contractual and reimbursement opportunities, and maintain compliance with payer and regulatory requirements. Acting as a primary liaison between facilities and payers, the Case Manager/ Prior Authorization Liason ensures effective communication, continuity of care, and optimal clinical and financial outcomes for SNF patients.
Essential Duties and Responsibilities Case Management & Utilization Review - Provide telephonic case management support to assigned skilled nursing facilities.
- Maintain active and accurate case files for SNF patients in PointClickCare (PCC), including Admin Notes, A/R insurance tabs, and shared Case Management logs.
- Review benefits verification and authorization data to ensure patients are placed at the appropriate level of care for contractual optimization; renegotiate rates when applicable.
- Notify MCOs of clinical admissions and initiate required clinical assessments.
- Review admission clinical documentation to determine appropriate target discharge plans.
- Conduct timely initial reviews, concurrent reviews, and continued stay reviews with MCOs to ensure covered days and reimbursement.
- Chair and facilitate weekly case conference calls with supported facilities.
- Assist facility interdisciplinary teams in developing appropriate goals of care and treatment plans for SNF patients.
- Coordinate all Notice of Medicare Non-Coverage (NOMNC) processes and track appeals in collaboration with facility teams.
- Obtain accurate payer information to support continuation of care and discharge planning.
Authorization & Referral Management - Represent the organization professionally to referral sources, managed care representatives, and external partners; maintain positive, collaborative relationships.
- Enter and manage referral leads, including Return to Acute (RTA) leads, in the PointClickCare CRM module.
- Verify insurance benefits and facility network participation through PCC, MCO portals, and direct payer communication.
- Submit, track, and follow up on all insurance authorization requests electronically or manually, as required.
- Update referral and authorization status throughout the PDG authorization and approval stages of the referral process.
- Coordinate physician assignment upon referral and authorization approval.
- Collaborate with Referral Management and Placement Specialists to ensure all coverage and documentation requirements are met.
- Communicate referral source or payer issues promptly to appropriate internal stakeholders.
- Negotiate appropriate levels of care and contracted rates with MCOs as necessary.
Care Coordination & Support Functions - Serve as the primary liaison between the MCO and facility for all case-related communication.
- Assist facilities in identifying in-network home health and durable medical equipment (DME) providers.
- Support billing and revenue cycle teams with authorization clarification, reimbursement issues, and census updates as needed.
- Participate in daily or routine pipeline and case review meetings as required.
- Perform additional duties within the Case Management Department as assigned to support organizational objectives.
Supervisory Responsibility This position has no direct supervisory responsibilities.
Required Education, Experience, and Skills - Active Nurse License
- Minimum of two (2) years of experience in:
- Skilled nursing facility case management, including initial reviews, concurrent reviews, and NOMNC processes, and/or
- Managed care verification of benefits and insurance authorization processes.
- Strong and demonstrated experience using PointClickCare software in a skilled nursing facility environment.
- Proficient computer skills, including Microsoft Outlook, Microsoft Office Suite, Microsoft Teams, and payer portals.
- Recent skilled long-term care experience required.
- Ability to make independent decisions using sound judgment and critical thinking.
- Self-motivated, self-directed, and able to work independently in a fast-paced environment.
- Excellent written and verbal communication skills.
- Strong organizational, negotiation, and relationship-management skills.
- Ability to establish and maintain effective working relationships with internal teams, facilities, and external organizations.
Position Type and Expected Hours of Work This position supports healthcare facilities that operate 24 hours per day, 7 days per week. While the role is primarily Monday through Friday, scheduled weekend and holiday coverage may be required based on business needs.
Work Environment and Physical Demands This position routinely uses standard office equipment, including computers, phones, and photocopiers. The work environment is primarily office-based with physical demands consistent with a professional healthcare management role.
Other Duties This job description is not intended to be a comprehensive list of all duties, responsibilities, or activities. Duties may change at any time with or without notice.
Reasonable Accommodation Reasonable accommodation may be made to enable individuals with disabilities to perform the essential functions of this position.
Job Tags
Work at office, Monday to Friday, Weekend work