Managed Care Case Manager

Friendship offers diverse senior living accommodations, award-winning care, new and innovative services, as well as specialized rehab and therapy, to over 1,000 residents and patients. The community opened its first building in 1966 and has grown to offer the full continuum of healthcare, including an adult day care center, home care services and Bistro '66, its dining venue that is open seven days a week. Friendship is a world-class community where the needs of adults and rehabilitations patients of all ages are met within a caring community that inspires purpose in life. Visit friendship.us for more information.

Friendship is seeking a Full Time Managed Care Case Manager (RN or LPN) to join our Friendship team, located on Hershberger Road. The Managed Care Case Manager will serve as the primary contact person for Case Managers/Utilization Review (UR) Managers, ensuring that all required information for concurrent reviews, UR reviews, etc. is gathered and submitted to support payment for the authorized level of care or advocate for a more appropriate authorized level of care. This role will be responsible for the Managed Care at all three skilled nursing facilities. 

 Roles & Responsibilities:

• Execution of the technical aspects of Managed Care Case management including, but not limited to:  
  • Assist with Pre-admission evaluation of potential Managed Care residents, and recommend care level of authorization to be requested.
  • Ensure thorough and timely communication with Managed Care/insurance Case Managers to coordinate certification and concurrent stay programs and promptly communicate with Managed Care/insurance company Case Managers as care needs of the residents change.
  • Review the clinical record, including but not limited to, nursing and therapy documentation for services being provided to meet levels of payment. Challenge documentation and request clarifying documentation, if necessary, prior to submitting to MCO (Managed Care Organization).
  • Ensure relevant documents including, but not limited to, Re-Authorizations, NOMNCs, ABNs, MCO specific forms, and any other Managed Care/insurance correspondences are scanned and uploaded into patient's electronic record.
  • Document Case Management process by tracking level of care, dates of service, and updating appropriate EMR files where such information is housed and tracked.
• Establish and maintain a positive working relationship with Facilities leadership and staff, residents, and families, and as well as all persons or agencies concerned with the well-being of the resident.
• Participate in weekly utilization review meeting for Managed Care residents.
• Communicate relevant information for Managed Care residents to the BOM, Social Services staff, and any Staff who will be overseeing and executing Care Coordination and DC Planning. 
• Communicate level of care changes and/or payer changes if applicable to BOM, for census changes.
• Facilitate and oversee the Managed Care Appeals process, including but not limited to oversight of the Managed Care Expedited Appeal process, and facilitating and/or conducting Peer-to-Peer appeals when necessary (in collaboration with Physician Liaison).
• Participate in Managed Care QUAD Check Process each month, prior to billing of Managed Care services.

Qualifications:

• Current LPN or RN license in good standing with the Virginia Department of Health Professions
• Post-acute clinical experience preferred
• MDS Knowledge preferred
• Ability to demonstrate excellent clinical, customer service, communication, and leadership skills
• Must maintain highest level of confidentiality to maintain HIPAA compliance
• Must be knowledgeable of and ensure compliance with federal and state regulations, center policies and procedures.
• Ability to collaborate and coordinate care with center interdisciplinary teams, Insurance and Managed Care organizations, ACO managers (Accountable Care Organization) and, third party payers.
• Must be flexible, detail-oriented, ability to multi-task, work independently with little oversight, meet deadlines, and be able to make effective decisions while working as part of a service excellence team.

• 401(k) retirement plan along with employer match
• Health Insurance
• Dental Insurance
• Vision Insurance
• Flexible Spending Account
• Paid Time Off
• Company Paid Life Insurance
• Education Assistance
• Voluntary insurance (additional life insurance, accident insurance, critical illness, short term disability)
• Employee Assistance Program

Friendship values diversity. We are committed to equal opportunities and creating an inclusive environment for all our employees. We welcome applicants regardless of race, color, ancestry, national origin, gender, sexual orientation, marital status, religion, age, disability, gender identity, results of genetic testing, or service in the military.