Clinical Reimbursement Consultant RN

JOB PURPOSE:

Coordinates the training of center partners and audits and provides recommendation for Process Improvement for the following areas:

• The RAI Process, the Care Management Process, and the use of various supporting software applications to ensure an appropriate level of Resident care and equitable and timely reimbursement of the care provided.

• Utilization of skilled Medicare services

• Medicare RUG, Medicaid Case Mix CMI / or Skilled Level of Care management

KEY RESPONSIBILITIES:

• Ensures current, new, and revised RAI / PPS / Case Mix information is distributed to appropriate partners in a timely manner.

• Provides information to regional and corporate staff on the status of clinical and financial reimbursement.

• Participates in national and state professional organizations that strengthen the company’s position and knowledge of the RAI process, Case Mix and clinical software programs.

• Provides information and education to center partners on the importance and use of the RAI and Care Plan, Medicare PPS, and State Case Mix and Skilled Level of Care processes and their correlation to resident care and reimbursement.

• Provides instruction on how to read, interpret and use the information contained in various state, federal, and company initiated and generated reports.

• Provides expertise, consultation and guidance to appropriate partners to ensure MDS accuracy and adherence to company policy and procedures, as well as state and federal regulations and guidelines based on information derived from audits and other available data.

• Identifies trends and areas of improvement and ensures an appropriate PI plan is completed, through analysis of financial and clinical reports.

• Maintains in-depth knowledge of the clinical software and billing system, the RAI process, and company initiated online support to help investigate and troubleshoot user-related software issues.

• Interviews applicants for the Case Mix Director / MDS Nurse and provides recommendations to the hiring authority.

• Oversees and coordinates the process for a thorough and timely orientation for new CMDs.

• Adheres to and oversees communication of privacy guidelines relative to the confidentiality of residents’ protected health information.

• Participates in PI activities as appropriate

• Frequent overnight travel may be required.

KNOWLEDGE, SKILLS, ABILITIES:

• Knowledge of state and federal regulations, both clinical and financial as it relates to the RAI process and reimbursement systems.

• Current Licensed Registered Nurse or Allied Health Care Professional in state of residence. Credential Nurse Assessment Coordinator preferred.

• Microsoft required

• Experience in MatrixCare, Pointright a plus

MINIMUM EDUCATION REQUIRED:

Bachelors’ degree from an accredited school of Nursing or other Allied Health Care Institution

MINIMUM EXPERIENCE REQUIRED:

Five- (5) years health care management, MDS Assessment & care Planning experience in multi-facility, long-term care organizations preferred.

Three (3) years clinical responsibility and experience with RAI process (MDS) required

MINIMUM LICENSURE/CERTIFICATION REQUIRED BY LAW:

Current, active license as a Registered Nurse or Allied Health Professional in the State practicing.

ADDITIONAL QUALIFICATIONS: (Preferred qualifications)

Software: MatrixCare and/or Pointright

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As an Equal Employment Opportunity employer, all qualified applicants will receive consideration without regard to race, color, religion, sex, national origin, disability, or veteran status.

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