Clinical Case Manager

Description

The Clinical Case Manager (CCM) is a licensed nurse responsible for coordinating and certifying the Resident Assessment Instrument (RAI) and Minimum Data Set (MDS) in compliance with federal and state regulations. The CCM collaborates with the interdisciplinary team to ensure accurate assessments, individualized care planning, PDPM compliance, and proper Medicare and Medicaid reimbursement while supporting quality, cost-effective resident care.

Essential Duties and Responsibilities:

• Manage the RAI process from admission through discharge to ensure clinical compliance and appropriate Medicare, Medicaid, and Managed Care reimbursement.
• Complete and submit accurate, timely, and documentation-supported MDS assessments in accordance with the RAI 3.0 User’s Manual.
• Review MDS analytics with the interdisciplinary team prior to submission; monitor validation reports and correct/re-submit rejected assessments within required timeframes.
• Conduct daily rounds on all Medicare Part A and Managed Care residents; identify changes in condition, initiate Significant Change MDS assessments, and update care plans with IDT input.
• Ensure completion of daily skilled documentation and nursing observation notes for all Medicare Part A and Managed Care residents.
• Assign appropriate ICD-10-CM codes to support skilled services.
• Coordinate physician certification and re-certification for Medicare Part A and Managed Care residents.
• Collaborate with the interdisciplinary team and Business Office Manager to support care planning, managed care authorizations, and clinical justifications.
• Attend required PPS, care plan, quality, and reimbursement meetings to identify changes impacting resident status or reimbursement.
• Issue Notices of Medicare Non-Coverage (NOMNC) as required.
• Ensure PASRR (PL1) compliance for all admissions per State of Texas guidelines.
• Provide training and support to nursing staff on ADLs and clinical case management responsibilities.
• Attend required training, meetings, and seminars.
• Performs other duties as assigned. 

Requirements

• Must be a Registered Nurse (RN) or Licensed Vocational Nurse (LVN) in good standing and currently licensed by the state. 
• Demonstrated proficiency in computer applications, including Microsoft Office and Outlook, with the ability to learn new systems.
• Minimum Data Set (MDS) and care planning experience preferred and working knowledge of Medicare and Medicaid programs preferred.
• Minimum of one (1) year of geriatric experience, preferably with supervisory experience.
• Must be able to interact positively with residents, families, and regulatory agencies, and work collaboratively with employees at all levels.
• Must be able to maintain consistent attendance and be willing to work long or irregular hours, often under pressure.

Physical Requirements:

• Must comply with all local health regulations and successfully complete a post-offer health assessment.
• Must be able to perform the essential functions of the position with or without reasonable accommodation.
• Physical and Sensory Requirements (with or without the use of mechanical devices):
• Ability to read, write, and speak fluent English to communicate effectively with residents, families, staff, and community agencies.
• Ability to perform physical activities such as walking, reaching, bending, stretching, pulling, and lifting.
• Adequate fine and gross motor coordination to carry out required tasks.

Work Environment:

• Long-term care facility setting.
• Exposure to residents with varying levels of care needs.
• May include evenings, weekends, holidays, and on-call shifts.

Core Competencies:

• Resident-centered care
• Professionalism and ethical conduct
• Team collaboration
• Problem-solving
• Cultural sensitivity and respect

Employer Statement:

The facility is an equal opportunity employer. Duties and responsibilities may change based on business needs.