Clinical Case Manager / MDS

Job Description

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.