As a Care Management Specialist, you’ll play an important role in making sure each resident’s needs are accurately assessed, documented, and reflected in their plan of care. Your work helps our interdisciplinary team understand changes in residents’ health and functional status while ensuring we meet important Medicare and Medicaid requirements.
This is a role where clinical knowledge, attention to detail, and teamwork directly impact resident care and the organization’s ability to provide the services our residents need. From completing MDS assessments and supporting care planning to monitoring reimbursement requirements and serving as a resource to facility staff, you’ll help connect clinical care, compliance, and operational success.
Responsibilities
- Assess residents’ health and functional status accurately and on time throughout their stay.
- Participate in pre-admissions to collect essential information for MDS/Case Mix optimization.
- Complete all Medicare/Medicaid case-mix documents promptly to ensure correct reimbursement.
- Collaborate with the Director of Rehab to use the appropriate assessment reference dates.
- Track Medicare/Managed Care eligibility and benefits through regular communication with care managers.
- Provide necessary information for Managed Care Utilization Reviews.
- Ensure compliance with Medicare requirements, including physician certification and recertification.
- Review MDS data concurrently to support appropriate RUG categorization.
- Collaborate with the interdisciplinary team on care planning and status changes.
- Complete all MDS assessments (Admission, Quarterly, Annual, PPS, Significant Change) according to RAI guidelines.
- Maintain an accurate MDS schedule and monitor for default or missed assessments, implementing corrective actions as needed.
- Perform assessment modifications/inactivations per CMS policy.
- Conduct regular audits of MDS processes and documentation accuracy.
- Ensure timely electronic submission of all MDS assessments and validate reports.
- Review QM and SNF QRP reports and take follow-up actions as required.
- Communicate with the Business Office and Administrator regarding case mix, RUG distribution, and reimbursement impact.
- Participate in Case Management, Level of Care, Triple Check, and other policy meetings.
- Support ADRs, Reconsiderations, and ALJ submissions as needed.
- Serve as a resource on RAI and Care Management for staff, including training new associates.
- Maintain knowledge of reimbursement regulations and organize department data efficiently.
- Demonstrate strong clinical assessment and documentation skills and support flexible business needs.
- Complete all MDS/RUGs training (AIS) within the first 90 days and ongoing as required
Qualifications
- Graduate of an accredited school of nursing with a current Texas R.N. or L.V.N. license
- Proficient with standard office software and MDS/RAI-related applications.
- Preferred experience with Point Click Care EMR software
- Strong initiative and ability to lead interdisciplinary teams and manage the RAI process efficiently
- Minimum of 2 years of healthcare experience
- Experience in MDS completion, reimbursement, clinical resource utilization, and/or case management is preferred
