Managed Care Case Manager

Majestic Care is looking for a Managed Care Case Manager to join our teams’ mission and believe in our core values!

Our mission :   Through the hearts of our Care Team Members, we provide excellent healthcare to those we serve.

Our Core Values...

L - Listening

E - Empathy

A - Accountability

D - Decisiveness

This is how we create a culture to LEAD with Love.

POSITION SUMMARY :

Through the hearts and minds of our care team members, we provide excellent healthcare to those we serve.   With a vision of innovating healthcare by keeping those we serve at the heart of our mission, we provide tools, processes, support resources, data analytics and insource strategies that drive results.   The Managed Care Case Manager plays a vital role in shaping and executing the strategy that will ensure the highest standards of patient care and Safety.

The Managed Care Case Manager is responsible for the coordination and oversight of managed care patients within the skilled nursing facility, including skilled inpatient (Part A), Part B therapy and ancillary services, and long-term care managed care residents . This role ensures optimal reimbursement, clinical appropriateness, regulatory compliance, and payer communication across assigned facilities. The Case Manager also contributes to interdisciplinary care planning, financial reviews, and credentialing processes.

Responsibilities

Skilled Inpatient (Part A) Case Management :

Secure initial authorization for all managed care admissions.

Conduct timely and accurate concurrent reviews using PointClickCare and payer-specific portals.

Submit clinical updates per schedule, documenting communications in PCC and any other systems required maintaining audit-ready files.

Coordinate appeals for denied days with clinical team input and track resolution outcomes.

Part B Therapy & Ancillary Services :

Obtain and track authorizations for therapy (PT / OT / ST) and ancillary services such as diagnostics, wound care, and labs.

Ensure utilization aligns with authorized units or timeframes; initiate reauthorization requests proactively.

Collaborate with therapy department to maintain continuity of care and compliance with payer requirements.

Long-Term Managed Care Residents :

Oversee new and reauthorizations as required by plans

Coordinate transitions of care and services with social services and family members.

Monitor Medicaid Managed Care payer updates and benefit changes.

Facility Operations & Collaboration :

Actively participate in Interdisciplinary Team (IDT) meetings to support coordinated care planning and discharge readiness.

Attend and contribute to monthly financial meetings , providing data on reimbursement trends, avoidable days, and payer mix.

Maintain and submit credentialing documents for managed care participation across all assigned facilities, collaborating with the business office or compliance as needed.

Cross-Functional Duties :

Interface with admissions, therapy, MDS, nursing, and billing to support timely, accurate care delivery and billing.

Participate in triple-check processes to ensure alignment between authorization, documentation, and claim submission.

Educate facility staff on managed care policies, changes in payer rules, and documentation best practices.

Education and Qualifications

Background in healthcare authorizations, SNF admissions, or case management required. Preferred LPN / RN, BA, BSW, CCM or other

Clinical background screening clinical packets for proper reimbursement leveling and capturing contract outliers / exclusions.

Proven leadership experience in a senior management role.

Strong understanding of healthcare regulations, compliance, and accreditation standards.

#HiMed