Responsible for the oversight and management of skilled patients and temporary skilled patients in rehabilitation in contracted Skilled Nursing facilities; this includes checking benefits, managing up to discharge and issuing denial letters. With primary care, specialist physicians and healthcare team, coordinates the implementation of a chronic disease care management program for patients. Coordinates with the assigned physician to manage Skilled nursing patients and directs families, patients, physicians, nurse practitioners and SNF staff to the appropriate level of care and identifies those patients who do not meet the criteria for Continued Skilled stay. Responsible for managing Custodial patients who require long term care for chronic disease management in SNFs. Complies with other duties as described. Must be able to work collaboratively with the Multidisciplinary team.

• In conjunction with physicians and healthcare team, develops an individual care plan based on patient assessment/evaluation and diagnostic tests.


• Monitors/evaluates patient progress and modifies treatment plan as appropriate in collaboration with the Multidisciplinary team.


• Recommends additional levels of care, therapy/rehabilitation when medically indicated as appropriate.


• Monitors levels and appropriateness of therapeutic and/or rehabilitative care.


• Implements strategies to assure that patients and caregivers comply with and understand the importance of follow through on plan of care in collaboration with the Multidisciplinary team.


• Provides individualized patient/family education which focuses on teaching self management.


• Conducts individual and team conferences to assist patients and family identify risk factors.


• Facilitates patients return to normal daily activities by teaching and making appropriate referrals for outside services/continued care collaboratively.


• In conjunction with physicians and healthcare team, develops treatment program procedures, clinical guidelines/protocols and program evaluation/outcomes measures.


• Educates the Inpatient Case managers about appropriateness of transfers to the Skilled Nursing facility and protocol for transfers.


• Ensures that the patient has a safe and appropriate discharge.


• Orders DME as ordered by the physician.


• Screens by using senior metrics for Skilled patient expected Length of Stay.


• Responsible for educating the Inpatient Case managers/designees about the appropriateness of admissions to the Skilled Nursing facility and protocols for admission.


• Intervenes when there are quality issues surrounding the transfers.


• Notifies members about the co-payment associated with the Skilled Nursing transfer.


• Communicates with physicians and other care givers regarding patient progress by monitoring, evaluating and analyzing clinical, functional and psycho-social status/progress.


• Issues reports.


• Participates in inter-disciplinary case conferences and consultations.


• Consults with the physician regarding the Senior metrics for the appropriate length of stay for the Skilled population.


• Contributes to medical and nursing staff education by giving periodic in-service presentations.


• Recommended to be present at the inpatient UM staff meetings.


• Participates in review/evaluation of the quality, appropriateness and outcomes of diagnostic and therapeutic services and treatment programs.


• Participates in committees, teams or other work projects/duties as assigned.