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Regional Case Manager

Summary:
The Case Management plays a critical role in centralizing and coordinating insurance authorization and case management functions across our multi-facility skilled nursing and long-term care network in Virginia. This position ensures timely authorization and continuation of care for residents under Medicare, Managed Care, Medicaid Managed Care, and commercial insurance plans. Working from our corporate office, the Case Management serves as a liaison between facility clinical teams, payers, and external partners to optimize reimbursement, reduce denials, and ensure compliance with payer requirements and CMS regulations.

Essential Duties & Responsibilities:

• Coordinate and obtain insurance authorizations for admissions, continued stays, and skilled service requests for all managed care and commercial payers.
• Serve as the primary contact between facility case managers, billing teams, and insurance representatives.
• Review clinical documentation to support medical necessity and communicate payer requirements to facility teams.
• Track and monitor authorization requests, approvals, and expirations to prevent lapses in coverage.
• Maintain detailed records of authorizations, payer communications, and denials.
• Ensure timely submission of clinical updates per payer requirements.
• Collaborate with facility MDS Coordinators, DONs, Administrators, BOM, and therapists to ensure clinical and financial alignment.
• Analyze trends in payer denials and delays; provide feedback and training to facility-level staff as needed.
• Support centralized case management workflow implementation and process improvements.
• Uphold all HIPAA, CMS, and state regulatory requirements in all documentation and communications.

Job Requirements:

• Education: Graduate of an accredited program, preferably with a healthcare background
• Licensure: Current and active nursing license in good standing, if applicable.
• Experience: Minimum of 2 years of experience in insurance authorization, utilization review, or case management within skilled/long-term care or managed care settings.
• Knowledge: Familiarity with Medicare Part A and B, Managed Care, and Virginia Medicaid Managed Care rules and processes.
• Skills:
• Strong critical thinking and clinical review skills.
• Excellent written and verbal communication.
• High attention to detail and organizational accuracy.
• Proficiency in EMR systems and payer portals.
• Ability to work independently and collaboratively in a fast-paced environment.

About Eastern Healthcare Group:

Eastern Health Group is a family of skilled nursing facilities and rehabilitation centers. We are resident-centered and quality-focused! Our workplace culture is all about uplifting people. We are committed to creating a nurturing, family-like atmosphere where staff develop meaningful relationships with residents and where exceptional patient outcomes are the standard.