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.