Grand Terrace Come join our team and start making a difference! Admissions and Authorization Management

• Review referrals and clinical documentation to determine appropriateness for SNF admission.
• Coordinate pre-admission assessments and payer eligibility verification.
• Obtain and manage insurance authorizations for Medicare Advantage, Managed Care, Commercial, and other payer sources.
• Collaborate with hospital discharge planners, physicians, and referral sources to facilitate and streamline care transition to SNF.
• Ensure timely communication with payers regarding clinical updates and authorization requests. Clinical Reimbursement and Care Coordination
• Lead and coordinate resident care planning activities with the interdisciplinary team.
• Participate in daily clinical meetings, utilization reviews, and care conferences.
• Monitor resident progress toward established goals and discharge plans.
• Identify barriers to care and implement interventions to improve outcomes.
• Facilitate communication among residents, families, physicians, therapists, nursing staff, and managed care companies.
• Section GG and PDPM Leadership + Serve as the clinical champion and facilitator for initial and discharge Section GG function score meetings. + Drive interdisciplinary collaboration between nursing, therapy, and MDS to ensure precise, accurate, and compliant functional scoring that reflects true patient care needs. Utilization and Length of Stay Management
• Monitor resident length of stay and utilization of services.
• Conduct concurrent reviews to ensure medical necessity and continued skilled coverage.
• Submit clinical updates and supporting documentation to managed care companies.
• Track authorization expirations and ensure uninterrupted coverage.
• Analyze payer trends and identify opportunities to optimize reimbursement and resident outcomes.

Utilization Defense:

Utilize objective clinical and functional data to build robust clinical justifications for continued skilled stay, effectively communicating functional deficits to managed care payers during concurrent reviews.

Peer-to-Peer and Appeals Managements:

Must have the clinical acumen to assist prepping the Medical Director for peer-to-peer reviews and execute expedited appeals when a managed care organization issues an inappropriate discharge. Discharge Planning and Care Transitions

• Coordinate with IDT on individualized discharge plans upon admission.
• Coordinate safe and effective transitions to home, assisted living, long-term care, or other settings.
• Arrange community resources, durable medical equipment, home health services, and follow-up appointments.
• Educate residents and families regarding discharge expectations and available resources.
• Monitor readmission risks and implement strategies to reduce avoidable hospitalizations.

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