Medical Claims Review Manager jobs in Clearwater, FL

The Case Manager plays an integral role in the success of our team, our community and in optimizing the plan of care for managed care and traditional Medicare patients associated with a value based initiative. The primary purpose of this position is to serve as the liaison between the patient, physician, interdisciplinary care team members, and the payer; this position coordinates, monitors, advocates and communicates the patients progress and cost evaluation while assisting with and coordinating an efficient and smooth coordination to the next level of care.

In this role, the Case Manager will divide their time between two facilities: Sabal Palms Health & Rehabilitation facility located on the Palms of Largo Senior Living campus located in Largo, FL & Westchester Gardens Health & Rehabilitation facility located in Clearwater, FL.

Sabal Palms Health & Rehabilitation is a 244 bed skilled nursing community and provides the support residents and patients need through a wide range of skilled nursing care, restorative therapies, memory care and pediatric care. This award-winning community is located on The Palms of Largo campus, which has been part of the Largo area since 1990.

Westchester Gardens Health & Rehabilitation is a 120 bed skilled nursing facility that continues to be recognized in the Clearwater community as a great place for senior living care and also has been recognized by US News & World Report as a Best Nursing Home; four years running. Westchester Gardens Health and Rehabilitation is a 5-star, beautiful community.

Essential Job Functions

• Knowledge of SNF reimbursement, managed care contracts, Medicare, Hospice, Medicaid and other value based payment sources in your assigned territory
• Negotiates appropriate levels of care for contracted and non-contracted terms with the payer case manager.
• Verify that all managed care admissions have an associated (PPO, HMO's, etc.) pre-authorization. Adjust authorization terms within first 3 days of facility stay if needed.
• Identify opportunities to capture exclusions and outlier payments based on patient needs. Assist teams in following process to capture these contractual benefits based on contract terms.
• Summarize, organize and forward all pertinent medical record information needed for concurrent review to Managed Care Insurance Case Managers as required per contract and at their request.
• Throughout patients stay adjust appropriate care levels as needed to ensure appropriate payments; work on interdisciplinary approach with all departments, attend daily Medicare/Managed Care Meetings to discuss therapy and/or nursing status.
• Case Manager will consult with Insurance Case Managers on clinical progress, concerns, barriers and assist Social Services Department with discharge planning.
• Communicates information to care team and assists with patient's smooth transition to the next level of care.
• Notify IDT of all payer source changes, discharges, transfers, etc. with all necessary departments.
• Interface and communicate effectively with hospital discharge planners, hospital social workers, insurance case managers, home health agencies.
• Consult with billing and operations teams on managed care collections procedure and process. Assist billing team with monthly A/R reviews to ensure accurate billing and timely collections.
• Perform other job-related duties as assigne

Knowledge and Critical Skills

• Be able to make independent decisions and follow instructions.
• Deal tactfully with personnel, patients, family members, visitors, government agencies/personnel, and the public.
• Capable of working with ill, disabled, elderly, and emotionally upset people within the facility.
• Communicate effectively in a manner that is sufficient for effective communication with supervisors, team members, prospects, residents, and families.
• Knowledge of Microsoft Office.

Education and Experience

• Must meet all applicable state and federal requirements for this position.
• Current and unrestricted licensed clinical degree preferred or bachelor’s degree in healthcare or related field.