Case Manager – HMO Skilled Nursing Focus

Location: Eddystone, Pennsylvania
Salary Range: $75,000 – $115,000 annually

Position Summary

We are seeking an experienced and detail-oriented Case Manager to support members within a Skilled Nursing Facility (SNF) and managed care/HMO environment. This role is responsible for coordinating patient care services, managing utilization review activities, and serving as a liaison between providers, facilities, and insurance payers to secure timely authorizations and reimbursement.

The ideal candidate will have strong knowledge of post-acute care, utilization management, insurance authorization processes, appeals and denial management, and interdisciplinary care coordination. Candidates may hold credentials as an LPN, RN, Master Social Worker (MSW), or Licensed Social Worker (LSW/LCSW), depending on state requirements and organizational needs.

Key Responsibilities

• Manage and coordinate care for members/residents in skilled nursing and post-acute care settings.

• Perform utilization management and concurrent review to ensure appropriate level of care and length of stay.

• Obtain and track insurance authorizations for admissions, continued stays, therapies, specialty services, and transitions of care.

• Communicate with HMOs, Medicare Advantage plans, commercial insurers, and other payers regarding clinical updates and authorization requirements.

• Prepare, submit, and monitor appeals for denied or reduced services, including writing clinical justifications and gathering supporting documentation.

• Review denial trends and collaborate with facility leadership to improve reimbursement outcomes and reduce avoidable denials.

• Coordinate interdisciplinary care planning with nursing, therapy, social services, physicians, and discharge planning teams.

• Facilitate safe and timely transitions of care, including discharge planning and community resource coordination.

• Maintain accurate and timely documentation in accordance with regulatory, payer, and organizational requirements.

• Ensure compliance with Medicare, Medicaid, managed care, and facility policies and procedures.

• Educate residents, families, and staff regarding insurance coverage, benefits, care planning, and discharge options.

• Participate in quality improvement initiatives related to utilization review, readmission reduction, and payer performance metrics.

Qualifications

Required

• Current and active licensure/certification in one of the following:

  • Licensed Practical Nurse (LPN)

  • Registered Nurse (RN)

  • Master Social Worker (MSW)

  • Licensed Social Worker (LSW/LCSW), depending on state requirements

• Minimum of 2 years of experience in case management, utilization review, managed care, skilled nursing, or post-acute care.

• Experience working with Medicare, Medicaid, Medicare Advantage, and commercial insurance plans.

• Strong understanding of authorization processes, payer guidelines, appeals, and denial management.

• Excellent communication, organizational, and documentation skills.

• Ability to manage multiple cases and deadlines in a fast-paced healthcare environment.

Preferred

• Certification in Case Management (CCM, ACM, or equivalent).

• Experience in SNF reimbursement and PDPM.

• Familiarity with electronic medical records (EMR/EHR) systems.

• Knowledge of state and federal regulatory requirements for skilled nursing facilities.

Skills & Competencies

• Utilization Management

• Insurance Authorization & Verification

• Appeals & Denial Resolution

• Care Coordination

• Discharge Planning

• Managed Care/HMO Processes

• Clinical Documentation Review

• Interdisciplinary Collaboration

• Critical Thinking & Problem Solving

• Time Management & Organization

Work Environment

• Skilled Nursing Facility (SNF), post-acute care, managed care organization, or hybrid setting.

• May require communication with external insurance representatives, hospitals, providers, and family members throughout the day.

Equal Opportunity Statement

We are an equal opportunity employer and is committed to creating an inclusive environment for all employees.

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