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.
Essential Duties and ResponsibilitiesFacility Outreach & Direct Billing Coordination
- 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
Insurance Verification & Issue Resolution
- 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
Documentation & Compliance
- 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
Team Collaboration
- 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
Benefits:
- Pay $25-29 and hour and quarterly bonus
- Health, Dental, Vision Insurance
- Generous 401 K plan
- Paid time off and holidays
- Life Insurance
- Education stipend
Great Place to Work® Certified!
Skilled Wound Care is proud to be Certified™ by Great Place to Work® for the 3rd year in a row. The prestigious award is based entirely on what current employees say about their experience working at Skilled Wound Care. This year, 95% of employees said it’s a great place to work – 39% higher than the average U.S. company.
Skilled Wound Care will ask all candidates to perform pre-employment confidential DiSC testing and appropriate relevant skills testing prior to hiring.
Skilled Wound Care, part of Skilled Physicians Group is an equal opportunity employer and does not discriminate on the basis of race, color, religion, sex (including pregnancy, gender identity, and sexual orientation), national origin, age (40 or older), disability or genetic information.
"SWC1"
Skills Required
- High school diploma or equivalent
- Minimum 2 years of experience in medical billing, insurance verification, or case management
- Working knowledge of Medicare Part A and Part B coverage rules
- Experience identifying and resolving insurance coverage gaps
- Strong communication and negotiation skills
What We Do
Skilled Wound Care is a subsidiary of Skilled Facility Health Care Solutions, Inc., a professional medical corporation, incorporated in 2007, that has been delivering advanced professional services in the Long Term Care Arena with a focus on cost effective patient care and increased patient satisfaction.
