Purpose of Your Job Position
As a Consulate Health Care Case Manager, you are entrusted with
the responsibility of caring for our residents, families,
co-workers, visitors and all others; as well as demonstrating in
all interactions, Consulate Health Cares five core values of
Compassion, Honesty, Integrity, Respect and Passion. The primary
purpose of your job position is to influence/management the cost
effectiveness of treatment and ancillary services through an
intimate relationship with therapy and nursing. You will be
involved in the care of all managed care patients starting at
pre-admission and continuing through payment for services provided.
You are entrusted to provide innovative, responsible healthcare
with the creation and implementation of new ideas and concepts that
continually improve systems and processes to achieve superior
As Case Manager, you are delegated the administrative authority,
responsibility, and accountability necessary for carrying out your
assigned duties. Responsible for monitoring and documenting the
cost effectiveness of treatment provided, facilitates and
coordinates the admission and discharge process, serves as the
resident family advocate and acts as a liaison to insurance and
management professionals. No supervisory function. This job
description does not list all the duties of the job. You may be
asked by supervisors or managers to perform other duties. You will
be evaluated in part based upon your performance of the tasks
listed in this job description. The employer has the right
to revise this job description at any time, for any reason.
Duties and Responsibilities
1. Participate in the admission process including pre-admission
assessment, rate negotiations, benefit verification, care needs and
2. Communicate resident status, change in function and care plan
either by phone or written report to payers.
3. Include payer representative in interdisciplinary meeting if
requested or deemed necessary to promote payer/provider
4. Document all payer interactions regarding resident progress,
expected outcomes and reporting capabilities including special
5. Ensures thorough and timely communication with managed
care/insurance case managers to coordinate certification and
concurrent stay programs.
6. Assist with the completion of the MDS for managed care
7. Negotiate all one-time payer agreements and LOAs with the
assistance of the Executive Director, District Director of Case
Management, and Vice President of Managed Care & Professional
8. Coordinate all services for each managed care patient,
including in home and outside of the care center.
9. Approves all payer changes affiliated with managed care
10. Reviews all ancillary invoices with Executive Director and
Business Office Manager.
11. Key communicator of discharge plans related to managed care
12. Review and challenge documentation before sending to
13. Maximize benefits by coordination of cost effective care,
avoid fragmented care, duplication of services and ensure the
appropriate level of care is provided in the most suitable
14. Meet with facility interdisciplinary team to coordinate
services to ensure that the residents total regimen of care is
15. Participate in all Medicare and managed care resident
16. Perform clinical assessments.
17. Work with team members to ensure discharge-planning goals
and objectives are developed and discussed at the interdisciplinary
18. Assist in planning the services required in the residents
discharge plan as necessary.
19. Maintain communication with facility business office and
medical records to ensure accurate census and payment of managed
care and Medicare residents.
20. Perform random chart reviews to ensure accurate and thorough
documentation to support reimbursement of services rendered.
21. Meet with residents, and/or family members, as necessary.
Report problem areas to department directors.
22. Agree not to disclose assigned user ID code and password or
accessing resident/facility information and promptly report
suspected or known violations of such disclosure to the Executive
23. Agree not to disclose residents protected health information
and promptly report suspected or known violations of such
disclosure to the Administrator.
24. Report any known or suspected unauthorized attempt to access
facilitys information system.
25. Assist with pre admissions evaluation of potential manage
care patients, including cost-cut, insurance authorization and
patient/insurance education as necessary.
26. Embrace Consulate Health Cares five core values of
compassion, honesty, integrity, respect and passion, and
incorporate them into ones daily job function.
27. Demonstrate respect and compassion in every interaction.
28. Conduct oneself with the highest degree of honesty and
integrity in every interaction.
29. Demonstrate a passion for caring as evidenced by interaction
with co- workers, residents, families and visitors.
30. May be trained and assigned to perform the Customer Care
Liaison duties as needed.
31. Perform all other duties, as assigned.
-Develop and maintain a good rapport with interdepartmental
personnel, as well as other departments within the facility to
ensure that services can be maintained to meet the needs of the
residents.-Make appropriate reports to department supervisors as
required or as may be necessary. Follow facilitys established
procedures.-Report known or suspected incidents of fraud to the
Executive Director.-Ensure that departmental computer workstations
left unattended are properly logged off or the password protected
automatic screen-saver activates within established facility policy
Nursing Care Function-Ensure that appropriate supplies and
equipment, etc., are available to meet the needs of assigned
residents.-Participate in the orientation of new resident/family
members to the facility.-Make rounds with physicians as
necessary.-Admit, transfer, and discharge Medicare and managed care
residents as required.
Budget and Planning Functions-Report suspected or known
incidence of fraud relative to false billings, cost reports,
Resident Rights-Maintain the confidentiality of all resident
care information. Report known or suspected incidents of
unauthorized disclosure of such information.-Review complaints and
grievances made by the resident and make a written/oral report to
the nursing manager indicating what action(s) were taken to resolve
the complaint or grievance. Follow the facilitys established
procedures.-Report all allegations of resident abuse and/or
misappropriation of resident property.
Miscellaneous-Provide data to the Quality Assurance Committee as
requested.-Participate in facility committees as
required.-Coordinate cost effective, quality care assuring that
cost containment does not take precedence over quality and
safety.-Participate in the development, maintenance, and
implementation of the facilitys quality assurance
program.Participate in facility surveys (inspections) made by
authorized government agencies as may be requested.
Degree in Nursing, preferred and/or equivalent experience in
-Must have, as a minimum, three (3) years experience in a
hospital, nursing care facility, or other related health care
-Must have training in rehabilitative and restorative nursing
-Must have a working knowledge of managed care rules,
regulations, and guidelines.
-Must have knowledge of managed care and PPS systems.
-Must possess a demonstrated knowledge of care management;
managed care, Medicare, utilization management practices, insurance
benefits and cost management strategies.
-Must possess knowledge of and demonstrated competency in
ensuring compliance with Medicare and third party reimbursement,
criteria/ levels of care.
-Must have knowledge of and experience with data base
applications to enable use of computerized MDS systems.
-Must possess demonstrated negotiation and prioritization
-Must have the ability to work in a matrix reporting system.
-Must be a supportive team member, contribute to and be an
example of teamwork and team concept.
-Must be able to read, write, speak, and understand the English
-Must possess the ability to make independent decisions when
circumstances warrant such action.
-Must possess the ability to deal tactfully with personnel,
residents, family members, visitors, government agencies/personnel,
and the general public.
-Must be knowledgeable of nursing and medical practices and
procedures, as well as laws, regulations, and guidelines that
pertain to managed care and nursing facilities.
-Must possess leadership and supervisory ability and the
willingness to work harmoniously with and supervise other
-Must possess the ability to plan, organize, develop, implement,
and interpret the programs, goals, objectives, policies and
procedures, etc., that are necessary for providing quality
-Must have patience, tact, a cheerful disposition and
enthusiasm, as well as the willingness to handle difficult
-Must be willing to seek out new methods and principles and be
willing to incorporate them into existing nursing practices.
-Must be able to relate information concerning a residents
-Must not pose a direct threat to the health or safety of other
individuals in the work place.
-Works in office area(s) as well as throughout the nursing
service area (i.e., drug rooms, nurses stations, resident rooms,
-Moves intermittently during working hours.
-Is subject to frequent interruptions.
-Is involved with residents, personnel, visitors, government
agencies/personnel, etc., under all conditions and
-Is subject to hostile and emotionally upset residents, family
members, personnel, and visitors.
-Communicates with medical staff, nursing personnel, and other
-Works beyond normal working hours and on weekends and holidays
-Is subject to call back during emergency conditions (e.g.,
severe weather, evacuation, post-disaster, etc.)
-Is involved in community/civic health matters/projects as
-Attends and participates in continuing educations programs.
-Is subject to injury from falls, burns from equipment, odors,
etc., throughout the workday, as well as reactions from dust,
disinfectants, tobacco smoke, and other air contaminants.
-Is subject to exposure to infectious waste, diseases,
conditions, etc., including TB and AIDS and Hepatitis B
-May be subject to the handling of and exposure to hazardous
-Maintains a liaison with the resident, their families, support
departments, etc., to adequately plan for the residents needs.