Lead Case Manager (LVN/RN)

Position Title: Lead Case Manager

Department: Case Management

Reports To: Director of Nursing

FLSA Status: Exempt

Job Summary:

The Case Manager is responsible for all case management activities assigned. This includes case management and utilization management. The Case Manager provides concise management of patients’ hospitalization from pre-admission through discharge in the areas of patient care, fiscal management, and Payor/referral satisfaction. The Case Manager is responsible for conducting Discharge Planning Evaluations, performing discharge planning to ensure patients and their families receive maximum benefits, and awareness of community and government agencies. This position requires the use of communication skills, the ability to perform management operations directly related to administrative goals and policies, to provide regular and direct assistance to executives, to perform work and special assignments under only very general supervision, and to continuously develop department operations toward efficiency and effectiveness.

Duties and Responsibilities (includes, but is not limited to the following):

• Obtain prior authorizations for procedures, services, and hospital admissions from insurance providers.


• Prepare and submit clinical documentation (clinicals) to support medical necessity and secure insurance approvals.


• Communicate regularly with insurance companies and third-party payers to verify coverage, obtain approvals, and resolve issues.


• Appeal and overturn insurance denials by gathering supporting documentation, writing appeal letters, and collaborating with providers.


• Coordinate with utilization review (UR) nurses and internal clinical teams to ensure compliance with payer requirements and standards of care.


• Track and document all communication, authorizations, denials, and appeals in the electronic medical record (EMR) or case management system.


• Monitor patient progress and collaborate with the care team to support discharge planning and continuity of care.


• Stay current on payer guidelines, authorization processes, and regulatory requirements.

• Admits new clients by reviewing records and applications; conducting orientations.


• Determines clients’ requirements by completing intake interviews; determining need for therapeutic medical, psycho-social, and psychiatric evaluations; reviewing therapist evaluations, treatment objectives, and plans.


• Establishes treatment programs by setting schedules and routines; coordinating services being provided; arranging resources, including transportation and escort.


• Monitors cases by verifying clients’ attendance; observing and evaluating treatments and responses; advocating for needed services and entitlements; obtaining additional resources; intervening in crises; providing personal support.


• Maintains clients’ records by reviewing case notes; logging events and progress.


• Communicates clients’ progress by conducting weekly interdisciplinary meetings and evaluations; disseminating results and obstacles to therapeutic team and family; identifying treatment influences.


• Prepares clients’ discharge by reviewing and amplifying discharge plans; coordinating discharge and post-discharge requirements; orienting and training family members; providing resources.


• Meets budget by monitoring expenses; implementing cost-saving actions.


• Prepares reports by collecting, analyzing, and summarizing treatment and results data and trends; compiling statistics; completing grant and subsidy applications.

Education, Licensure and/or Certifications

• Current California LVN or RN license


• Three (3) years of work experience in a medical case management setting preferred.

Experience and Qualifications

Good organizational and liaison capabilities with well-developed written and verbal communication abilities are required. Well demonstrated public relations skills with a cooperative and assertive attitude. Working knowledge of the insurance industry is required.

• Have an understanding of the commercial insurance appeal process.


• Have a working knowledge of billing ad reimbursement and letter of agreement.


• Be knowledgeable regarding pre-certification and concurrent review process.


• Must have clear and concise professional language in the preparation of up to date clinical reports representing the patient’s total condition and treatment plan.


• Have working knowledge of Federal and State Regulatory Compliance.


• Have a good working knowledge and ability to facilitate interdisciplinary team conference identifying clinical challenges and outstanding issues.


• Ability to discharge patients successfully without adverse health consequences with all needs identified.

Supervisory

• Case Management personnel

Other Skills and Abilities

• Maintains confidentiality of patients at all times


• Sensitivity to and willingness to interact with persons of various social, cultural, economic and educational backgrounds.


• Proficiency with Microsoft Office applications including Outlook, Word, Excel and PowerPoint.


• Strong organizational skills with ability to prioritize projects, work relatively independently, manage multiple tasks, and meet deadlines.


• Strong written and verbal communication skills.


• Ability to work independently and as part of a team.


• Good judgment, problem solving and decision-making skills.


• Demonstrated commitment to working collaboratively as well as possessing the skills to lead, influence, and motivate others.


• Ability to work in a fast-paced, expanding organization.

Physical Demands: The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job.  Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

• Movement within a complex hospital environment


• Ability to write by hand, use keyboard and mouse extensively to perform general office functions


• Ability to communicate by speech and hearing continuously


• Must have visual acuity near and far (20 inches to 20 feet), depth perception, field of vision, ability to focus on an object, ability to identify and distinguish colors


• Ability to sit and stand for extended periods of time


• Ability to occasionally stoop, kneel, crouch, and walk


• Ability to grasp, hold and pick up and reach with hands and arms


• Ability to occasionally lift and carry up to 25 pounds (periodic lifting of supplies or equipment)

Work Environment:  The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job.  Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. 

While performing the duties of this job, the employee is regularly exposed to hospital areas and general office environment.  The work environment is a clean, well-lit, well-ventilated, and temperature controlled environment.  The noise level in the work environment is usually moderate.  The hours of duty are lengthy and irregular.

Acknowledgment:  This job description in no way states or implies that these are the only duties to be performed by the employee incumbent in this position.  The Employee may be required to follow any other job-related instructions and to perform any other job-related duties requested.  This document does not create an employment contract, implied or otherwise, other than an "at-will" relationship. 

Employee Name __________________________________

Employee Signature __________________________________      Date __________________