The Clinical Reimbursement Coordinator (RN) manages the overall process and tracking of all Medicare/Medicaid case-mix documents in order to assure appropriate reimbursement for services provided within the Center. Conducts concurrent MDS reviews to assure achievement of maximum allowable RUG categories. He/she will integrate information from nursing, dietary, social services, restorative, rehabilitation and physician services to ensure appropriate reimbursement. RESPONSIBILITIES/ACCOUNTABILITIES:
1. RevenueOptimization - Resource Utilization:
1.1 Tracks Medicare Customers to determine continued and appropriate Medicare eligibility and benefit period by determining skilled level of need;
1.2 Prior to admission, reviews pre-admission intake information with the External Care Coordinator or Admissions Coordinator to estimate RUG levels for Medicare Customers and to identify potential resource costs, consider formularies, and communicate findings to Administrator/care team;
1.3 Performs concurrent MDS review to insure appropriate RUGs category is achieved through the capture of appropriate clinical information. Identifies opportunities to enhance reimbursement;
1.4 Directs the interdisciplinary team process to communicate opportunities to ensure capturing of all resources;
1.5 Collaborates with Reimbursement Services to review RUG reports and identify RUG categorization.
2. MDS Schedule and Tracking:
2.1 Maintains an accurate schedule of all MDS assessments to include the proper reference dates throughout the Customer's stay and ensures the accurate and timely submission of the MDS assessments including case-mix, OBRA and OSRA required assessments;
2.2 Communicates to the Care Plan Coordinator the MDS assessment schedule to ensure timely facilitation of the care planning process.
2.3 Completes the admission and discharge tracking form and maintains tracking system for admission/re-entry/discharge;
2.4 Manage the data entry function to ensure the accuracy of the MDS and verify electronic transmissions to Genesis and the state.
3.1 Coordinate with the Center Business Office, and or/Centralized Business Office when available throughout the month, to communicate case-mix data required for billing such as RUGs categories, modifiers, state case-mix scores, etc.
4. Education and Resource:
4.1 Serves as the Center resource for MDS/RUGs and state case-mix systems;
4.2 Provides case-mix education to the interdisciplinary team as appropriate;
4.3 Instructs Center staff in terminology, language, and format that is required by MDS;
4.4 Communicates with Center Administrator, interdisciplinary team and Reimbursement Services regarding any changes in case-mix regulations such as PPS and/or state specific case-mix systems;
4.5 Trains backup personnel for the Clinical Reimbursement Coordinator;
5. Other Duties
5.1 Assists in the preparation of all requests from appropriate State and/or federal regulatory agencies or agents regarding payment of services (reconsideration, denials appeals, etc.);
5.2 Maintains all reports and transmission data in a systematic format and stores in a safe, locked area;
5.3 Maintains a current and comprehensive knowledge of MDS and Medicare/ Medicaid reimbursement;
5.4 Implements all required forms, procedures and processes relative to job responsibilities;
5.5 Performs other related duties as requested.
- Complies with applicable legal requirements, standards, policies and procedures including but not limited to those within the Compliance Process, Standard/Code of Conduct, Federal False Claims Act and HIPAA.
- Participates in required orientation and training programs.
- Promptly reports concerns and suspected incidences of non-compliance to supervisor, Compliance Liaison or to the Compliance Officer via the Integrity Hotline.
- Cooperates with monitoring and audit functions and investigations.
- Participates, as requested, in quality assurance and process improvement activities.
SPECIFIC EDUCATIONAL/VOCATIONAL REQUIREMENTS: 1. Graduate of an accredited School of Nursing with current RN licensure in the state in which employment occurs is required. 2. One year of long term care clinical nursing experience is required. 3. Experience with Medicare/Medicaid reimbursement, MDS completion, clinical resource utilization and/or case management is highly desirable. 4. Experience with basic computer technology. 5. This position requires that the employee is able to read, write, speak and understand the spoken English language to ensure the safety and wellbeing of our patients and visitors at the work site when responding to their medical and physical needs. 6. Maintains current BLS/CPR certification (excluding ALFs/ILFs). Position Type:
Full TimeReq ID:
Raton Nursing and Rehab CenterJob Salary: