Purpose of Your Job Position
As a Consulate Health Care Case Manager, you are entrusted with the responsibility of caring for our residents, families, co-workers, visitors and all others; as well as demonstrating in all interactions, Consulate Health Care's five core values of Compassion, Honesty, Integrity, Respect and Passion. The primary purpose of your job position is to influence/management the cost effectiveness of treatment and ancillary services through an intimate relationship with therapy and nursing. You will be involved in the care of all managed care patients starting at pre-admission and continuing through payment for services provided. You are entrusted to provide innovative, responsible healthcare with the creation and implementation of new ideas and concepts that continually improve systems and processes to achieve superior results.
As Case Manager, you are delegated the administrative authority, responsibility, and accountability necessary for carrying out your assigned duties. Responsible for monitoring and documenting the cost effectiveness of treatment provided, facilitates and coordinates the admission and discharge process, serves as the resident family advocate and acts as a liaison to insurance and management professionals. No supervisory function. This job description does not list all the duties of the job. You may be asked by supervisors or managers to perform other duties. You will be evaluated in part based upon your performance of the tasks listed in this job description. The employer has the right
to revise this job description at any time, for any reason.
Duties and Responsibilities
1.Participate in the admission process including pre-admission assessment, rate negotiations, benefit verification, care needs and reporting.
2.Communicate resident status, change in function and care plan either by phone or written report to payers.
3.Include payer representative in interdisciplinary meeting if requested or deemed necessary to promote payer/provider relationship.
4.Document all payer interactions regarding resident progress, expected outcomes and reporting capabilities including special instructions.
5.Ensures thorough and timely communication with managed care/insurance case managers to coordinate certification and concurrent stay programs.
6.Assist with the completion of the MDS for managed care patients.
7.Negotiate all one-time payer agreements and LOA's with the assistance of the Executive Director, District Director of Case Management, and Vice President of Managed Care & Professional Services.
8.Coordinate all services for each managed care patient, including in home and outside of the care center.
9.Approves all payer changes affiliated with managed care patients.
Reviews all ancillary invoices with Executive Director and Business Office Manager.
Key communicator of discharge plans related to managed care patients.
Review and challenge documentation before sending to MCO.
Maximize benefits by coordination of cost effective care, avoid fragmented care, duplication of services and ensure the appropriate level of care is provided in the most suitable setting.
Meet with facility interdisciplinary team to coordinate services to ensure that the resident's total regimen of care is maintained.
Participate in all Medicare and managed care resident interdisciplinary meetings.
Perform clinical assessments.
Work with team members to ensure discharge-planning goals and objectives are developed and discussed at the interdisciplinary team meetings.
Assist in planning the services required in the resident's discharge plan as necessary.
Maintain communication with facility business office and medical records to ensure accurate census and payment of managed care and Medicare residents.
Perform random chart reviews to ensure accurate and thorough documentation to support reimbursement of services rendered.
Meet with residents, and/or family members, as necessary. Report problem areas to department directors.
Agree not to disclose assigned user ID code and password or accessing resident/facility information and promptly report suspected or known violations of such disclosure to the Executive Director.
Agree not to disclose resident's protected health information and promptly report suspected or known violations of such disclosure to the Administrator.
Report any known or suspected unauthorized attempt to access facility's information system.
Assist with pre admissions evaluation of potential manage care patients, including cost-cut, insurance authorization and patient/insurance education as necessary.
Embrace Consulate Health Care's five core values of compassion, honesty, integrity, respect and passion, and incorporate them into one's daily job function.
Demonstrate respect and compassion in every interaction.
Conduct oneself with the highest degree of honesty and integrity in every interaction.
Demonstrate a passion for caring as evidenced by interaction with co- workers, residents, families and visitors.
May be trained and assigned to perform the Customer Care Liaison duties as needed.
Perform all other duties, as assigned.
Nursing Care Function-Ensure that appropriate supplies and equipment, etc., are available to meet the needs of assigned residents.-Participate in the orientation of new resident/family members to the facility.-Make rounds with physicians as necessary.-Admit, transfer, and discharge Medicare and managed care residents as required.
Budget and Planning Functions-Report suspected or known incidence of fraud relative to false billings, cost reports, kickbacks, etc.
Resident Rights-Maintain the confidentiality of all resident care information. Report known or suspected incidents of unauthorized disclosure of such information.-Review complaints and grievances made by the resident and make a written/oral report to the nursing manager indicating what action(s) were taken to resolve the complaint or grievance. Follow the facility's established procedures.-Report all allegations of resident abuse and/or misappropriation of resident property.
Miscellaneous-Provide data to the Quality Assurance Committee as requested.-Participate in facility committees as required.-Coordinate cost effective, quality care assuring that cost containment does not take precedence over quality and safety.-Participate in the development, maintenance, and implementation of the facility's quality assurance program.Participate in facility surveys (inspections) made by authorized government agencies as may be requested.
Degree in Nursing preferred and/or equivalent experience in Healthcare Management (RN preferred).
Must have, as a minimum, three (3) year's experience in a hospital, nursing care facility, or other related health care facility.
Must have training in rehabilitative and restorative nursing practices.
Must have a working knowledge of managed care rules, regulations, and guidelines.
Must have knowledge of managed care and PPS systems.
Must possess a demonstrated knowledge of care management; managed care, Medicare, utilization management practices, insurance benefits and cost management strategies.
Must possess knowledge of and demonstrated competency in ensuring compliance with Medicare and third party reimbursement, criteria/ levels of care.
Must have knowledge of and experience with data base applications to enable use of computerized MDS systems.
Must possess demonstrated negotiation and prioritization skills.
Must have the ability to work in a matrix reporting system.
Must be a supportive team member, contribute to and be an example of teamwork and team concept.
Must be able to read, write, speak, and understand the English language.
Must possess the ability to make independent decisions when circumstances warrant such action.
Must possess the ability to deal tactfully with personnel, residents, family members, visitors, government agencies/personnel, and the general public.
Must be knowledgeable of nursing and medical practices and procedures, as well as laws, regulations, and guidelines that pertain to managed care and nursing facilities.
Must possess leadership and supervisory ability and the willingness to work harmoniously with and supervise other personnel.
Must possess the ability to plan, organize, develop, implement, and interpret the programs, goals, objectives, policies and procedures, etc., that are necessary for providing quality care.
Must have patience, tact, a cheerful disposition and enthusiasm, as well as the willingness to handle difficult residents.
Must be willing to seek out new methods and principles and be willing to incorporate them into existing nursing practices.
Must be able to relate information concerning a resident's condition.
Must not pose a direct threat to the health or safety of other individuals in the work place.
Works in office area(s) as well as throughout the nursing service area (i.e., drug rooms, nurses' stations, resident rooms, etc.).
Moves intermittently during working hours.
Is subject to frequent interruptions.
Is involved with residents, personnel, visitors, government agencies/personnel, etc., under all conditions and circumstances.
Is subject to hostile and emotionally upset residents, family members, personnel, and visitors.
Communicates with medical staff, nursing personnel, and other department directors.
Works beyond normal working hours and on weekends and holidays when necessary.
Is subject to call back during emergency conditions (e.g., severe weather, evacuation, post-disaster, etc.)
Is involved in community/civic health matters/projects as appropriate.
Attends and participates in continuing educations programs.
Is subject to injury from falls, burns from equipment, odors, etc., throughout the workday, as well as reactions from dust, disinfectants, tobacco smoke, and other air contaminants.
Is subject to exposure to infectious waste, diseases, conditions, etc., including TB and AIDS and Hepatitis B viruses.
May be subject to the handling of and exposure to hazardous chemicals.
Maintains a liaison with the resident, their families, support departments, etc., to adequately plan for the residents' needs.
Where Will Compassion Take You?
At Consulate Health Care, we're looking for talented, compassionate and hard-working individuals who are eager to serve others. Our team members go above and beyond to give our residents and patients the care they deserve - so you'll find that every day with Consulate Health Care offers new and exciting opportunities to learn and grow.
Compassionate hearts and passionate dedication - these two qualities shine in our team members and provide the foundation for our mission of "Providing Service With Our Hearts and Hands". The compassion you'll show to residents, patients and their families is the lifeline of our business, while relationships with your peers and coworkers will strengthen our vibrant, diverse community.
Consulate Health Care is one of the nation's leading providers of Senior healthcare services, specializing in post-acute care. Operating in 21 states, we offer services ranging from short-term transitional care to Alzheimer's and dementia care.
24-hour skilled nursing care
Comprehensive post-acute care
Physical, Occupational and Speech therapies
"Your Journey Home" short-term rehab program
Alzheimer's and dementia care
Care for medically-complex patients
Consulate Health Care