Nurse Case Manager

## Description

**Paradigm Healthcare LLC is Hiring a Licensed Nurse Case Manager**

In keeping with the organization’s goals, the Case Manager/ Prior Authorization Liaison- Managed Care Department, is responsible for providing comprehensive telephonic case management, insurance verification, and authorization services for our skilled nursing facilities (SNFs). This role supports the managed care continuum from referral and admission through ongoing utilization review, discharge planning, and continuation of care.

The position partners closely with Managed Care Organizations (MCOs), referral sources, and facility leadership to promote managed care census growth, ensure appropriate levels of care, maximize contractual and reimbursement opportunities, and maintain compliance with payer and regulatory requirements. Acting as a primary liaison between facilities and payers, the Case Manager/ Prior Authorization Liason ensures effective communication, continuity of care, and optimal clinical and financial outcomes for SNF patients.

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**Essential Duties and Responsibilities**

**Case Management & Utilization Review**

• Provide telephonic case management support to assigned skilled nursing facilities.
• Maintain active and accurate case files for SNF patients in PointClickCare (PCC), including Admin Notes, A/R insurance tabs, and shared Case Management logs.
• Review benefits verification and authorization data to ensure patients are placed at the appropriate level of care for contractual optimization; renegotiate rates when applicable.
• Notify MCOs of clinical admissions and initiate required clinical assessments.
• Review admission clinical documentation to determine appropriate target discharge plans.
• Conduct timely initial reviews, concurrent reviews, and continued stay reviews with MCOs to ensure covered days and reimbursement.
• Chair and facilitate weekly case conference calls with supported facilities.
• Assist facility interdisciplinary teams in developing appropriate goals of care and treatment plans for SNF patients.
• Coordinate all Notice of Medicare Non-Coverage (NOMNC) processes and track appeals in collaboration with facility teams.
• Obtain accurate payer information to support continuation of care and discharge planning.

**Authorization & Referral Management**

• Represent the organization professionally to referral sources, managed care representatives, and external partners; maintain positive, collaborative relationships.
• Enter and manage referral leads, including Return to Acute (RTA) leads, in the PointClickCare CRM module.
• Verify insurance benefits and facility network participation through PCC, MCO portals, and direct payer communication.
• Submit, track, and follow up on all insurance authorization requests electronically or manually, as required.
• Update referral and authorization status throughout the PDG authorization and approval stages of the referral process.
• Coordinate physician assignment upon referral and authorization approval.
• Collaborate with Referral Management and Placement Specialists to ensure all coverage and documentation requirements are met.
• Communicate referral source or payer issues promptly to appropriate internal stakeholders.
• Negotiate appropriate levels of care and contracted rates with MCOs as necessary.

**Care Coordination & Support Functions**

• Serve as the primary liaison between the MCO and facility for all case-related communication.
• Assist facilities in identifying in-network home health and durable medical equipment (DME) providers.
• Support billing and revenue cycle teams with authorization clarification, reimbursement issues, and census updates as needed.
• Participate in daily or routine pipeline and case review meetings as required.
• Perform additional duties within the Case Management Department as assigned to support organizational objectives.

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• **Supervisory Responsibility**
• This position has no direct supervisory responsibilities.