Weekend Case Manager (Coverage and Weekend)

Description: Position Overview: Case Manager (Coverage & Weekend) The Coverage & Weekend Case Manager is responsible for ensuring continuous case management coverage while obtaining, managing, and maintaining authorizations across all lines of business, including Skilled (Prior Authorization), Part B (Outpatient Therapy), and Custodial (Long-Term Care). REQUIRED SCHEDULE is 4 ten hour days- F/S/S/M. This role ensures seamless workflow continuity, strong client communication, timely authorization execution, and adherence to turnaround time expectations. The position plays a critical role in supporting weekend operations and cross-functional coverage to maintain consistent client outcomes. This role reports to the Weekend & Coverage Case Manager Supervisor. Key Results Areas Maintains full responsibility for assigned caseload and all coverage caseloads, ensuring continuity of service and positive client outcomes. Provides coverage across all case management functions, including Prior Authorization, Part B, Custodial, and Weekend workflows. Maintain accurate, real-time documentation within Guided Care systems. Ensure coverage notes are consistently updated to support seamless case transitions. Collaborate across teams to support additional caseload needs during high-volume periods, weekends, and coverage gaps. Responds to all authorization requests within 20 minutes of receipt. Submits authorization requests timely and provides a minimum of two (weekend) and three (weekday) daily updates on pending cases. Completes:

• Minimum 150 authorizations monthly (KPI expectation) – during weekend.
• Additional volume as required for coverage support

Maintains an error rate of less than 2 per month after 90 day onboarding period. Reviews all authorization packets for completeness and ensures only required clinical documentation is submitted. Coordinates and submits appeals, ensuring timely follow-up with the appeals team. Completes daily census verification by 11:00 AM (facility time zone) and communicates payer changes accordingly. Part B & Benefit Review Responsibilities Responds to Part B requests within 30 minutes. Completes benefit verifications within less than 60 minutes turnaround. Submits and manages Part B authorizations, including obtaining additional visits as needed. Ensures no Part B authorizations remain pending greater than14 days. Maintains organized documentation and clear communication across all requests. Custodial Authorization Management (Long-Term Care) Manage long-term care authorization requests while covering Reviews daily census for payer changes and initiates updates accordingly. Interprets medical records to support medical necessity and submission requirements. Regulatory Notices & QIO Appeal Management - Weekend Responsible for handling DENCs, NOMNCs, and QIO notices in accordance with CMS and payer guidelines. Ensures timely submission of QIO appeals within required regulatory timeframes. Completes all QIO appeal submissions and documentation within Creatio. Follow up proactively with QIO entities, as needed. Provides timely client updates on appeal status, determinations, and next steps. Client Communication & Service Excellence Maintains a high level of professionalism and customer service across all communication channels. Responds to all client inquiries by EOD (minimum standard). Provides education and guidance to clients regarding authorization processes and system usage. Communicates proactively regarding workflow issues, payer updates, delays, or risks. Process Improvement & Accountability Updates leadership on payer-specific requirements to support Guide to Obtain accuracy. Identifies workflow inefficiencies and communicates improvement opportunities. Participates in team collaboration, training, and process improvement initiatives. Demonstrate strong organizational skills to manage multiple workstreams simultaneously. Professional Expectations Maintains excellent attendance and adherence to HR policies. Communicates respectfully and professionally with colleagues and leadership. Participates in team building and company initiatives. Upholds Guided Care principles (GUIDE) in all interactions. Performs other duties as assigned. Requirements:

• Associate or Bachelor’s degree preferred (or equivalent experience).
• High School Diploma or GED required.
• 3+ years of healthcare experience, including prior authorization processing.
• Skilled nursing, admissions, or business office experience preferred.
• Strong understanding of payer requirements and authorization workflows.
• Highly organized with strong attention to detail.
• Ability to manage high-volume workload in a fast-paced environment.
• Strong time management and ability to meet strict deadlines.
• Effective communication and relationship-building skills.
• Ability to work independently in a remote environment.
• Demonstrates discretion and maintains confidentiality at all times.
• Proficiency in Microsoft Office and ability to learn new systems.

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