Clinical Case Manager (CCM)

The Clinical Case Manager (CCM) is a licensed nurse responsible for coordinating and certifying the Resident Assessment Instrument (RAI) and Minimum Data Set (MDS) in compliance with federal and state regulations. The CCM collaborates with the interdisciplinary team to ensure accurate assessments, individualized care planning, PDPM compliance, and proper Medicare and Medicaid reimbursement while supporting quality, cost-effective resident care.

Essential Duties and Responsibilities:

• Manage the RAI process from admission through discharge to ensure clinical compliance and appropriate Medicare, Medicaid, and Managed Care reimbursement.
• Complete and submit accurate, timely, and documentation-supported MDS assessments in accordance with the RAI 3.0 User’s Manual.
• Review MDS analytics with the interdisciplinary team prior to submission; monitor validation reports and correct/re-submit rejected assessments within required timeframes.
• Conduct daily rounds on all Medicare Part A and Managed Care residents; identify changes in condition, initiate Significant Change MDS assessments, and update care plans with IDT input.
• Ensure completion of daily skilled documentation and nursing observation notes for all Medicare Part A and Managed Care residents.
• Assign appropriate ICD-10-CM codes to support skilled services.
• Coordinate physician certification and re-certification for Medicare Part A and Managed Care residents.
• Collaborate with the interdisciplinary team and Business Office Manager to support care planning, managed care authorizations, and clinical justifications.
• Attend required PPS, care plan, quality, and reimbursement meetings to identify changes impacting resident status or reimbursement.
• Issue Notices of Medicare Non-Coverage (NOMNC) as required.
• Ensure PASRR (PL1) compliance for all admissions per State of Texas guidelines.
• Provide training and support to nursing staff on ADLs and clinical case management responsibilities.
• Attend required training, meetings, and seminars.
• Performs other duties as assigned.