Case Manager

The Case Manager – SNF & Insurance Coordination is responsible for investigating and resolving complex insurance coverage issues for patients receiving care in Skilled Nursing Facilities. This role focuses on situations where coverage is incomplete, unverified, or unbillable through standard processes — including patients with Medicare Part A only, no insurance, or placement in hospital-owned or county facilities — and works directly with facilities and payers to identify viable billing solutions.

• Negotiate and establish direct billing agreements or arrangements with facilities where applicable
• Document all outreach, agreements, and billing resolutions in the appropriate systems
• Serve as the primary point of contact between the billing department and SNF facilities for unresolved or problematic accounts

• Verify insurance eligibility and coverage details for patients with unclear or unspecified payer information
• Identify patients who have Medicare Part A only and determine appropriate next steps for coverage or billing
• Work with payers, Medicaid, and managed care plans to resolve coverage disputes and clarify billing responsibility
• Manage insurance denials and appeals related to SNF stays and coverage determinations

• Maintain accurate and timely documentation of all account activity, outreach efforts, and resolution outcomes
• Ensure all billing and outreach activities comply with HIPAA, CMS guidelines, and applicable state and federal regulations
• Track and report key metrics to leadership on coverage resolution outcomes and outstanding issues
• Participate in billing and credentialing meetings to provide updates and flag trends in coverage gaps

• Work closely with the billing and credentialing team to identify and prioritize complex coverage cases
• Collaborate with clinical staff, social workers, and care coordinators to obtain information needed to resolve coverage issues
• Provide feedback to leadership on recurring billing issues or systemic coverage gaps that require process changes

• High school diploma or equivalent required; Associate's or Bachelor's degree in healthcare administration, business, or a related field preferred
• Minimum 2 years of experience in medical billing, insurance verification, or case management
• Working knowledge of Medicare Part A and Part B coverage rules, particularly as they apply to SNF stays
• Experience identifying and resolving insurance coverage gaps or unspecified payer accounts
• Familiarity with county hospital systems and hospital-based nursing facility billing limitations
• Strong communication and negotiation skills, particularly when contacting external facilities and payers
• Ability to manage and prioritize a high volume of accounts independently

• Experience working in a billing, credentialing, or revenue cycle environment
• Knowledge of Medicaid billing requirements and managed care payer processes
• Certified Case Manager (CCM) or experience in utilization review
• Proficiency with electronic health record and practice management systems (e.g., Epic, Cerner, PointClickCare)
• Experience establishing direct billing arrangements with facilities