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