Regional Clinical Reimbursement Specialist

Job Description

Job Description

ALLIANCE HEALTH MANAGEMENT SERVICES

JOB DESCRIPTION AND PERFORMANCE APPRAISAL

STAFF NAME:_________________________________________ JOB TITLE: Regional Clinical Reimbursement Specialist

EMPLOYEE #:_____________ HIRE DATE:________________ APPRAISAL PERIOD:______________ TO ______________

POSITION PURPOSE:

· Assess and evaluate the quality of care being given to Alliance facility residents per CMS guidelines.

· Oversees and Ensures completion of MDS interviews and assessments following the RAI process.

· Ensuries regulatory compliance of Medicare, Medicaid, and Managed Care by following federal and state guidelines.

INTERPERSONAL RELATIONSHIPS:

· Coordinate with facility team to ensure implementation of the residents’ plan of care, assessments, and education.

· Works with corporate team to ensure compliance, report any and all issues, and educate as needed.

EDUCATIONAL REQUIREMENTS:

· Graduate of an accredited School of Nursing (LPN, RN, or BSN). RN preferred.

PHYSICAL REQUIREMENTS:

· Physical health sufficient to meet the ergonomic standards and demands of the position and its location. Regular and consistent attendance at the facilities as needed.

EXPERIENCE REQUIRED:

· Minimum 2 years clinical experience in a long-term care setting. Prior MDS/RAI experience

· Demonstrated clinical assessment skills.

· Knowledge of Medicare and Medicaid regulations and coverage guidelines related to skilled nursing.

SUPERVISORY RESPONSIBILITIES:

· Dotted line supervision of facility based MDS Coordinators

PROFESSIONAL LICENSURE AND CERTIFICATION REQUIRED:

· Current/active Massachusetts Nursing license

· RAC-CT certification preferred.

· BLS CPR certification

REPORTING RELATIONSHIPS:

· Direct report to the Corporate Director for Clinical Reimbursement

· Dotted line relationships to:

o Corporate Director of Clinical Services

Issued by:______________________________________________

Approved by:___________________________________________

Review Date:____________________________________________

JOB DESCRIPTIONS/

RESPONSIBILITY

MDS COORDINATOR

PERFORMANCE INDICATORS

MEASUREMENT CRITERIA/

COMMENTS

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Administrative Functions

· Serves as corporate lead for either short stay PDPM PPS MDS process or OBRA based long term care OBRA MDS (including MA based Medicaid PDPM based payment process).

· Review the current AHMS Clinical Reimbursement (CR) Policies and Procedures for respective area, recommend modifications.

· Determine compliance with established policy. Develop and utilize a facility reporting process to ensure facility compliance with established policies. This includes both remote monitoring and onsite audits.

· Evaluate current clinical reimbursement documentation forms and assessments to ensure facilities capture the care provided and maximize reimbursement.

· Provide CR transition training to the organization to ensure that trainees gain functional knowledge, and the organization is prepared for the transition.

· Serve as a resource to CR staff for problem solving and real time education as needed for respective area.

· Ensure that all submissions are accurate, timely, and fully compliant with current rules and regulations.

· Conduct random audits of active and previously submitted MDS’s.

· Review Point Right data and make recommendations as needed.

· Review clinical documentation and make recommendations to improve as needed.

· Assist with end of month process.

· Assist the other Lead as needed.

Facility Support

· Evaluate current facility CR Nurses’ skills sets and provide observations, assessments, and recommendations.

· Serve as a resource to CR staff for problem solving and real time education as needed.

· Review and assist in all ARD requests from third party payers.

· Conduct onsite audits and reviews of entire CR process. Conduct exit review with facility staff with findings and clear objectives.

· Review and audit PASRR/NOMNC submissions

· Review respiratory compliance and effectiveness.

· Assist facilities with QM ratings objectives.

· Participate in end of month activities as required.

· Cover other regional’s facilities as needed.

Personnel Functions

· Follows work assignments, and/or work schedules to complete assigned tasks. Performs all assigned tasks in accordance with established policies and procedures.

· Cooperates with interdepartmental personnel, as well as other departments within the facility to assure that services are properly maintained to meet the needs of the residents.

· Develops and maintains a good working rapport with interdepartmental personnel.