About this role
Grand Terrace
Come join our team and start making a difference!
Admissions and Authorization Management
• Review referrals and clinical documentation to determine appropriateness for SNF admission. • Coordinate pre-admission assessments and payer eligibility verification. • Obtain and manage insurance authorizations for Medicare Advantage, Managed Care, Commercial, and other payer sources. • Collaborate with hospital discharge planners, physicians, and referral sources to facilitate and streamline care transition to SNF. • Ensure timely communication with payers regarding clinical updates and authorization requests. Clinical Reimbursement and Care Coordination
• Lead and coordinate resident care planning activities with the interdisciplinary team. • Participate in daily clinical meetings, utilization reviews, and care conferences. • Monitor resident progress toward established goals and discharge plans. • Identify barriers to care and implement interventions to improve outcomes. • Facilitate communication among residents, families, physicians, therapists, nursing staff, and managed care companies. • Section GG and PDPM Leadership • Serve as the clinical champion and facilitator for initial and discharge Section GG function score meetings. • Drive interdisciplinary collaboration between nursing, therapy, and MDS to ensure precise, accurate, and compliant functional scoring that reflects true patient care needs.
Utilization and Length of Stay Management
• Monitor resident length of stay and utilization of services. • Conduct concurrent reviews to ensure medical necessity and continued skilled coverage. • Submit clinical updates and supporting documentation to managed care companies. • Track authorization expirations and ensure uninterrupted coverage. • Analyze payer trends and identify opportunities to optimize reimbursement and resident outcomes. • Utilization Defense: Utilize objective clinical and functional data to build robust clinical justifications for continued skilled stay, effectively communicating functional deficits to managed care payers during concurrent reviews. • Peer-to-Peer and Appeals Managements: Must have the clinical acumen to assist prepping the Medical Director for peer-to-peer reviews and execute expedited appeals when a managed care organization issues an inappropriate discharge. Discharge Planning and Care Transitions
• Coordinate with IDT on individualized discharge plans upon admission. • Coordinate safe and effective transitions to home, assisted living, long-term care, or other settings. • Arrange community resources, durable medical equipment, home health services, and follow-up appointments. • Educate residents and families regarding discharge expectations and available resources. • Monitor readmission risks and implement strategies to reduce avoidable hospitalizations.
Regulatory and Compliance Responsibilities
• Maintain compliance with CMS, Medicare, Medicaid, state regulations, and managed care requirements. • Ensure accurate and timely documentation supporting skilled services and payer requirements. • Participate in audits, surveys, and quality improvement initiatives. • Maintain confidentiality and comply with HIPAA regulations. Quality and Performance Management
• Monitor key performance indicators including: • Average Length of Stay (ALOS) • Readmission Rates • Authorization Denial Rates • Managed Care Performance Metrics • Discharge-to-Community Outcomes • Quality Measures Outcomes
• Participate in process improvement initiatives to enhance resident care and operational performance. • Support facility goals related to quality measures and value-based care programs. For benefit details check us out here http://ensignbenefits.com/
Benefits eligibility for some benefits dependent on full time employment status.
Disclaimer: Pay rates are competitive and determined by various factors. Please note that any rates labeled as "estimated" are provided by third-party job boards and may not accurately reflect the actual pay rates.
EOE disability veteran