Case Manager (Skilled Nursing) – Managed Care-HMO (RN/LPN/LMSW/LCSW)

Job Title: Case Manager – HMO (SNF Focus)
Location: Eddystone, Pennsylvania
Salary Range: $75,000 – $115,000 annually

About the Role:
We are seeking an experienced and detail-oriented HMO Case Manager to support patients in Skilled Nursing Facility (SNF) settings. This role is responsible for coordinating care, managing utilization, and ensuring appropriate clinical outcomes and reimbursement within the Pennsylvania market.

Key Responsibilities:

• Manage a caseload of SNF patients under HMO plans

• Oversee prior authorizations, continued stay reviews, clinical updates, denials, and appeals

• Coordinate and submit clinical documentation to insurance providers in a timely manner

• Monitor case progress and advocate for appropriate levels of care and reimbursement

• Ensure denial letters and NOMNCs are issued and submitted promptly

• Collaborate with interdisciplinary teams, including facility staff, providers, and insurance case managers

• Participate in utilization review meetings and conduct daily census reviews (admissions, payer changes, discharges)

• Maintain accurate, thorough, and timely documentation of all case activities and communications

Qualifications:

• Active and unrestricted RN, LPN, LMSW, or LCSW license required

• Minimum 3 years of relevant experience in SNF, HMO, or case management

• Strong understanding of prior authorizations, utilization review, and reimbursement processes

• Knowledge of Pennsylvania healthcare market and payer systems

• Experience with EMR systems and insurance portals

• Excellent organizational, communication, and multitasking skills

Why Join Us:
This is an opportunity to play a critical role in patient advocacy and care coordination within a collaborative and fast-paced healthcare environment. Your expertise will directly impact patient outcomes, optimize reimbursement processes, and support operational success across the organization.

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