Lead Clinical Nurse Reimbursement Specialist

Full Time | Day Shift

** Pay rate between $38.67-47.65/hour **(based on experience)

The Friendly Home is a 5-star Senior Care Community, located in Brighton, NY - we embrace and live our values every day: Friendship, Teamwork, Compassion, Excellence, Integrity, and Customer Focus. Because Friends Care Always!

Requirements for a Friendly Home Lead Clinical Nurse Reimbursement Specialist:

• R.N./B.S.N. preferred.
• Experience in Long Term Health Care, as well as current experience in MDS 3.0, RUGS reimbursement methodology, Medicare regulations and the Patient Driven Payment Model
• Current New York State RN License

Responsibilities for a Friendly Home Lead Clinical Nurse Reimbursement Specialist:

• Oversees the coordination of the RAI process, schedule all OBRA required and PDPM assessments for all assigned residents according to state and federal regulations; and ensure that the IDT adheres to the schedule.
• Responsible for overall operations of Clinical Reimbursement Department, including supervision of Clinical Nurse Reimbursement Specialist and MDS Per Diem staff.
• Oversees Quality Performance Measures; monitors and manages Quality Measures for accuracy and optimization; performs chart reviews on MDS and care plans as necessary to identify patterns/trends and opportunities for Quality Improvement.
• Facilitates effective meetings (Medicare, CMI, Grand Rounds) to ensure thorough communication of pertinent information to IDT and maintain a strong team approach to optimizing reimbursement, and ensure compliance with accurate and timely billing.
• Evaluates and determines Medicare and continued Medicare coverage for both new admissions and readmissions, utilizing current criteria.
• In conjunction with IDT reviews all PDPM MDSs for appropriate and timely documentation and coding to ensure compliance and accuracy in scoring.
• Oversees the management of the Medicaid only case mix to ensure compliance and optimization.
• Identifies and assures the availability of supporting documentation that will optimize reimbursement from both internal and external (hospitals, outpatient facilities, etc.) sources.
• Reviews all Medicare A MDS's 3.0 for content accuracy and appropriate RUGS's codes prior to submission.
• Reviews all Medicaid MDS's 3.0 for appropriate and accurate documentation prior to submission.
• Tracks therapy minutes to comply with Medicare guidelines communicate and set up appropriate MDS's and communicate to finance department.
• Continual oversight and assessment of IDT staff competency related to compliance and reimbursement documentation, process, and requirements; collaborates with Nurse Educator to provide education to ensure compliance.
• Provides training to new staff on MDS completion in Health MedX.
• Tracks new admissions that are technically eligible for Medicare, but do not have skilled needs for the first thirty days following admission, to identify possible eligibility.
• Communicates to Nurse Managers when a Member is Medicare covered and why to ensure necessary supporting documentation.
• Responsible to investigate and correct findings by the Medicare consultant.
• Oversee and assist with all payment related external audits
• Stays abreast of changes in any MDS, RUGS, PDPM, CMI, and Medicare reimbursement systems.
• Serves as Clinical Liaison for HMO's and Communicate to HMO's/Medicare Advantage ensures that documentation and updates are completed.
• Manages all appeals for Medicare A & B.
• Obtains all authorization numbers for Medicare B Members for skilled therapy.

About The Friendly Senior Living:

• We embrace independence and personal choice in a culture of excellence where we live our values - always.
• U.S. News & World Report ranked Friendly Senior Living "Best Nursing Home 2022-2023" in both categories: Short-Term Rehabilitation and Long-Term Care!
• One of the few local long term care facilities to receive a 5-star rating!
• Selected as a 2023 Elevating Women honoree by Rochester Business Journal

Our excellence is based upon the dedication of ALL our employees, who take great pride in providing compassionate care and services to our Members.

Benefits offered by the Friendly Senior Living:

• Sign-on Bonus (if applicable)
• Competitive Pay with Evening, Night, and Weekend Shift Differentials
• No Mandated Shifts
• Pay On Demand Option (Get Paid Immediately!)
• Tuition Assistance & Professional Growth Opportunities
• On-site Employee Cafeteria
• PTO / Paid Holidays / Paid Sick Time
• Medical / Dental / Vision
• 403(b) Retirement Plan
• Supportive culture that values Friendship, Teamwork, Compassion, Excellence, Integrity, and Customer Focus.

Friendly Home is an equal opportunity employer. All applicants will be considered for employment without attention to race, color, religion, sex, sexual orientation, gender identity, national origin, veteran, disability status or any other status protected by laws and regulations.