Regional Clinical Reimbursement Specialist
| Verified Pay check_circle | Provided by the employer150USD per year |
|---|---|
| Hours | Full-time |
| Location | Southborough, MA 01772 Southborough, Massachusetts open_in_new |
About this job
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
list specific examples for 1 - 5 ratings Key*
1
2
3
4
5
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.
Your Privacy Choices