Lead Reimbursement Coordinator/MDS/Case Manager

The facility Lead MDS Case Management Reimbursement Coordinator is responsible for adequately assessing nursing facility residents’ needs using state, federal, and commercial processes that promote positive clinical and financial outcomes. RN is preferred.

The Lead MDS Case Management Reimbursement Coordinator (LRC) works with the interdisciplinary team to develop, revise, update, and maintain a comprehensive care plan and ensure that compliance is maintained with state and federal guidelines. The LRC is responsible for attesting to the completion of the Minimum Data Set (MDS), which is the key driver for Medicare and Medicaid payment and many quality reporting functions. The LRC serves as the resource for the Patient-Driven Payment Model (PDPM), Case Management Functions, manages Additional Development Requests, Medicaid Case-Mix and is responsible for complying with ethical standards when setting ARDs, completing assessments, driving documentation and upholding State and Federal requirements.

The LRC assists with the coordination of care delivery by applying advanced nursing clinical skills, completing assessments, analyzing data, educating team members, and coordinating the exchange of resident information across the care settings.

ESSENTIAL FUNCTIONS

This list is only partial and should not be interpreted as a comprehensive inventory of all duties, tasks, and responsibilities.

· Oversee the ADR process and appeals/denial management within the facility up to and including ALJ level according to company guidelines.

· Provides support and oversight of the Skilled and OBRA documentation and analyzes facility data to provide favorable clinical and financial outcomes

· Provides oversight of the reimbursement department to ensure appropriate coverage, assignment of duties, and work flow to achieve department goals and objectives.

· Provide oversight of the RAI process, which includes the MDS, Care Area Assessment Process, care plan development, implementation, evaluation and assists with MDS completion and transmission to the national repository. Review final validation reports and corrections or modifications in response to warnings or errors as needed.

· MDS Coding accuracy across all disciplines and Quality Measure monitoring and program oversight to assure accurate reporting of clinical information that impacts 5 star ratings and Quality Reporting Programs

· Responsible for care coordination as well as clinical assessment and fiscal management of short term skilled beneficiaries. Completes MDS assessments as required according to regulatory guidelines for those beneficiaries.

· Notifies the resident or the appropriate family advocate of the resident’s status in regards to whether or not the resident is eligible for Medicare and the reasons the decision was based on in accordance with the regulations.

· Facilitate effective, well organized utilization meetings, establish productive objectives and follow through with action plans

· Works with team members to obtain accurate and complete documentation to support ICD-10-CM diagnosis coding. Sequences for claims and updates diagnoses in electronic medical record according to clinical changes/updates and at a minimum upon admission and quarterly.

· Engage facility management team in problem solving process to identify improvement opportunities and achieve solutions

· Works effectively with individuals at all levels of the organization, as well as with residents, family members, visitors and outside agencies

· Adheres to company policies and processes that impacts all areas of job functions

· Possess the ability to plan, organize, develop, implement and interpret the programs, goals, objectives, policies and procedures, etc., that are necessary for ensuring the accurate and timely completion of the RAI documents.

· Participates in CQI as deemed necessary by the Director of Nurses

· Assists with related duties as may be deemed necessary by the Administrator and/or DON.

· Fosters effective working relationships and maintains confidentiality of sensitive information

· Plan, organize, prioritize, work independently and meet deadlines

Job Type: Full-time

Pay: $45.00 - $50.00 per hour

Benefits:

• Dental insurance
• Disability insurance
• Health insurance
• Life insurance
• Paid time off
• Referral program
• Vision insurance

Medical specialties:

• Geriatrics

Physical setting:

• Long term care
• Nursing home
• Rehabilitation center

Schedule:

• Monday to Friday

Supplemental pay types:

• Signing bonus

Work Location: One location

Salary : $45 - $50