Applications are submitted online until the position is filled and/or the posting is closed. After reviewing this job announcement, please click on the link at the bottom of the page to apply online. A resume is required with the application. Further instructions on submission of documents are available in the online application. A resume may not be substituted for an application.

Reporting to the Regional Center Administrator, the Licensed Practical Nurse (LPN) Case Manager plays an integral role in ensuring complex health cases are managed appropriately, along with continuity of care, preventing readmissions, and enhancing patient outcomes. This specialized position requires a unique blend of clinical and/or administrative nursing expertise, exceptional communication skills, and a compassionate, patient-centered approach.  Currently, there are four (4) vacancies, one (1) in each of the four Kane locations, Glen Hazel, McKeesport, Scott Township, and Ross Township. Vacancies and locations available are subject to change as vacancies are filled.

Case Management

• Works with insurance companies and staff to obtain initial and ongoing authorizations for patients in advance of services.
• Researches, corrects, and resubmits rejected/denied insurance authorizations. Identifies missing, insufficient, or inconsistent clinical information and proactively obtains clarifications from providers.
• Reviews the accuracy and completeness of information requested to ensure that all supporting documents are present.
• Serves as a liaison between the prior authorization team, ordering providers, nursing staff and care coordination teams.
• Conducts clinically informed review of provider orders, documentation, and medical records to determine medical necessity based on payer guidelines and evidence-based criteria.
• Reviews denial trends and recommends clinical-focused process improvements to reduce avoidable denials.

 

 Care Management (Transition/Discharge Planning)

• Assess patients' needs and create comprehensive discharge/transition plans.
• Coordinates with healthcare providers to ensure continuity of care during transitions.
• Educates patients and families on post-discharge care instructions.
• Conducts follow-up calls and visits to ensure compliance with discharge plans.
• Identifies potential barriers to successful care transitions and develop solutions.
• Advocates for patient needs and preferences throughout the transition process.
• Documents and maintains detailed patient records and discharge/transition plans.

 

General/Compliance

• Reports noncompliance with policies, procedures, regulations, or breaches in confidentiality to appropriate personnel. Reports any retaliation or discrimination to HR or compliance officer.
• Reports any allegations of abuse, neglect, misappropriation of property, exploitation, or mistreatment of residents to supervisor/Administrator/Abuse Coordinator. Protects residents from abuse and cooperates with all investigations. 

 

Performs any/all other duties as required.

• Center for Medicare and Medicaid Services (CMS) regulations.
• Electronic health record (EHR) systems.
• Case, care and utilization management principles and protocols.
• Community resources and support services provision

• Clinical and/or administrative nursing or personal care.
• Knowledge of Microsoft Office Suite and basic computing systems.

 

• Problem solves using logical reasoning or critical thinking aptitude.
• Communicate effectively both orally and in writing.
• Collaborate, interact and engage effectively with patients, residents, teams, and other stakeholders.
• Utilize interpersonal skills to acknowledge and support concerns and demonstrate empathy or understanding
• Develop and implement care and case management plans.
• Be productive and plan, organize, and manage time effectively and efficiently.
• Advocate for, promote and protect the rights of patients and residents.
• Treat all residents with dignity and respect.
• Establish a culture of compliance by adhering to all facility policies and procedures. 
• Comply with standards of business conduct and state/federal regulations and guidelines.