The posting
Job Description
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
About Us
Regency Integrated Health Services, Wellsential Health, Senior Solutions Pharmacy, Nurse Practitioner Services of Texas, and Texas Independent Health Care Plan are all an Equal Opportunity Employer. We do not discriminate on the basis of race, religion, color, sex, gender identity, sexual orientation, age, disability status, national origin, veteran status or any other basis covered by appropriate law. All employment decisions are based on legitimate, non-discriminatory criteria.
Wellsential Health is the largest Texas-based non-profit, skilled nursing organization, representing more than 65 skilled nursing and rehabilitation centers across the state. Our mission is to make better health and wellness possible for all Texans by delivering compassionate, high-quality care in the communities we serve. As a non-profit partner, we reinvest in our residents, our facilities, and our people—because our purpose is care, not profit.
Our team members are dedicated professionals who bring heart, integrity, and commitment to improving quality of life every day. At Wellsential Health, we believe caring for our team is just as important as caring for our residents. When our team members feel supported, valued, and well cared for, they can provide the highest level of care in return. If you’re looking for meaningful work where you can make a lasting impact, Wellsential Health is the place to grow your career and serve with purpose.
