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Regional Insurance Case Manager 

About the Organization CommuniCare Family of Companies is a privately held, multi-faceted healthcare management company in operation since 1984 that specializes in nursing homes, assisted living facilities and rehabilitation units. Our company's historic passion for excellence is evident in every facet of our service continuum. We are leaders in the long-term care industry and operate over 40 facilities across Ohio, Pennsylvania, Maryland and Missouri, employing more than 7,000 dedicated care personnel. We're excited about your interest in joining CommuniCare and your desire to uphold our mission of Caring with Purpose and Caring with Pride.  
Location Information  

Regional Insurance Case Manager

Due to continued growth, the CommuniCare Family of Healthcare Companies is seeking the right nursing professional for the newly created position of Regional Insurance Case Manager for the Cleveland, OH region.

The Regional Insurance Case Manager reports to the Corporate Director of Managed Care and Case Management and is responsible for providing Managed Care oversight to ensure appropriate clinical services are provided and optimal reimbursement is received for each resident. This includes ensuring that the centers are in compliance with Medicare regulations, managed care contracts, and the CommuniCare Family of Companies' guidelines, policies and procedures. This role serves as an integral member of the facility's management team in helping the facility develop quality Managed Care programs.

Job Duties include:

  • Oversees clinical reimbursement and case management services within the region for Insurance Managed Care patients to ensure appropriate care is rendered and appropriate reimbursement is obtained.
  • Negotiates with the service providers, payers, and members of the center's care team to meet the resident's care needs. (Includes: labs, x-rays, pharmacy, rehab, ambulance, equipment and supply needs, etc.)
  • Advocates on behalf of resident and facility for needed resident resources and services within the reimbursement continuum.
  • Provides education to other health care providers, the facility's care team, and the resident/family on Managed Care.
  • Acts as liaison between the facility, insurance companies, resident/family, Rehab and other care providers to communicate residents' needs to insurance providers while representing facility and resident interests.
  • Monitors documentation requirements that support services provided to meet billing requirements.
  • Oversees Managed Care residents and coordinates rehabilitation, optimal recovery, and discharge planning.
  • Completes chart audits to assess the quality of the documentation to support skilled Managed Care coverage
  • Oversees the completion of cert/recerts, all non-coverage notices for Managed Care.
  • Ensures Managed Medicaid Part A and Part B are appropriately billed and meet Medicare documentation guidelines.
  • Oversees the resource utilization of services covered under consolidated billing as well as the ancillary costs
  • Directs the completion of RFAI claims requests and appeals for denied Managed Care claims.
  • Knows the latest Managed Care contract guidelines, outliers, and contracts to ensure care is provided and billed appropriately
  • Ensures compliance with all regulations regarding state specific case mix
  • Works with facility Marketing team to market Managed Care program's assets and outcomes.
Position Requirements
  • Graduate of an accredited School of Nursing, LPN or RN
  • Valid Nursing license in the state employed
  • Three years experience in a long term care environment working directly with Managed Care Services is preferred
  • Experience with the MDS/RAI process and/or case management
  • Demonstrates basic clinical assessment skills to meet the job requirements
  • Ability to communicate effectively with residents and their family members and staff at all levels of the organization
  • Knowledge of Medicare and Medicaid (Case Mix) regulations
  • Knowledge of the RAI process, including the MDS, RAP's and Care Plan
  • Must maintain CPR certification
Full-Time/Part-Time Full-Time  
Location Cleveland Region  
Shift -not applicable-  
Experience Level Three or more years  
Education Level Nursing License - LPN or RN  

This position is currently not accepting applications.

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