MDS - Clinical Reimbursement Coordinator RN

POSITION DESCRIPTION

POSITION TITLE: Clinical Reimbursement Coordinator

REPORTS TO:  Nursing Home Administrator

DEPARTMENT: Nursing

The primary responsibility of your job position is to direct, coordinate and lead MDS Systems, Medicare A, Medicare B and all other insurance providers, as well as conduct care coordination for case management following the current federal, state and local standards, guidelines and regulations that govern long term care and assisted living facilities.   Incumbent is delegated the administrative authority, responsibility, and accountability necessary for carrying out your assigned duties to ensure appropriate reimbursement for services provided within the Center.

KEY RESPONSIBILITIES:

•  Coordinates and manages the process of information and clinical integration from the Interdisciplinary Team (IDT): nursing, dietary, social services, restorative nursing, physician services and the rehabilitation team to ensure the appropriate level of skilled need and capturing of all resources

• Perform clinical assessments and manage the data entry of residents in all care areas needed to complete regulatory/PPS and other reimbursement related MDS forms and ensure accuracy of the MDS including timely submission of the transmission process   

• Maintains current and comprehensive knowledge of MDS and Medicare/Medicaid reimbursement

• Serves as Center resource for MDS/RUGS and Case Mix systems

• Coordinates with the Business Office Manager required billing data such as: RUGs, case mix data, and insurance authorization required for billing accuracy

• Assist with writing and updating Care Plans in collaboration with IDT

• May direct the restorative nursing program

• Assess residents for need for restraints and obtain all needed consents and physician’s orders

• Assists with coordination of the process of assessing incontinent residents for need for bladder or bowel retraining or toileting programs.

• Assist with implementation of adaptive behavior programs and other interventions consistent with the care plan for each individual resident.

• Assist with strategies and training of Center staff in terminology, language, and format that is required for capturing the highest burden of care delivered to residents and is responsible for implementation of strategies to ensure quality outcomes and fiscal responsibility for the community assessments.

• Assists with leadership within the community participating in weekly and monthly triple check, QA&A, PIC, Care Conferences, Daily Standup and PPS

• Participate in pre-admission assessments and the decision making process regarding new admissions by calculating potential resource expenses, and estimate clinical reimbursement

• Complete Quality Management Reports based on Quality Measures; assists in developing collaborative IDT action plans and report on process and outcomes of these action plans

• Participate and assist in Clinical Center Programs such as: Restraint Management, Pain Management, Quality Management, Fall Management, and Medication Review

• Assist in evaluation of the effectiveness of policies and procedures and make suggestions for revision in the interest of more effective and efficient services

• Perform administrative duties such as evaluations, studies and audits as needed      

• Helps maintain the physical, social and psychological environment

• Ability to maintain professional working relationships with all Center personnel, residents and families; present a professional image to the consumer through dress, behavior and speech

• Participate in new staff general orientation

• May serve on committees such as infection control, safety, Performance Improvement, Adaptive Behavior and Culture Change.  May serve as chair of some of these committees; attends department supervisor and staff meetings

• Must follow all safety procedures; reports accident/incident hazards; assist with infection control in identifying risks; follows established infection and universal precautions policies and procedures; monitor the use and handling of equipment to ensure safe usage and avoid waste or breakage

• Maintain confidentiality of all pertinent resident care information as well as staff information; adheres to HIPAA

• Trains backup personnel for the Clinical Reimbursement Coordinator

• Complete “Nonviolent Crisis Intervention” training per facility protocol

• Perform all other duties as assigned

TALENT:

Relationship Building

Have a caring attitude and sincere interest in others

Demonstrate friendliness and enthusiasm

Build relationships with all types of people

Influencing

Communicate effectively

Flexibility

Executing

Self-directed

Ability to organize and prioritize

Ability to exercise judgment and display understanding

Detail oriented and follow through

Strategic Thinking

Solve problems effectively

Creative in coming up with options and variety

Curiosity and desire to learn 

SKILLS AND KNOWLEDGE:

• Maintains strong working knowledge of the Resident Assessment Instrument (RAI) Manual as well as complete the required courses for credentialing through the American Association of Nurse Assessment Coordinators and maintain certification thereafter

• Prefer knowledge of Medicare/Medicaid and insurance reimbursement procedures, contracts, clinical resource utilization and/or case management (can be trained)

• Must have basic computer operation and typing skills for efficient data input; must be able to navigate touchscreen computers

• Knowledgeable of nursing and medical practices and procedures as well as regulations and guidelines that pertain to long term care must have knowledge of office machines and equipment

• Must demonstrate the knowledge and skills necessary to provide care appropriate to the age-related needs of the residents served

• Must be knowledgeable of laws, regulations, and guidelines pertaining to hospital and nursing facility administrative procedures

EDUCATION AND EXPERIENCE:

• Graduate from an accredited school of nursing

• Current RN license in the State of Colorado required

• Must have, as a minimum, three (3) years’ experience in an administrative supervisory capacity in a hospital or nursing facility

• Experience in rehabilitation and/or geriatric nursing is desirable

JOB TRAINING: 

• How long it usually takes to completely perform this job when the incumbent has the minimum knowledge, skills, abilities, work experience and/or education: up to 1 year

WORK ENVIRONMENT:

• Works in all areas of the facility 

• Moves intermittently during working hours

• Is subject to frequent interruptions

• Is involved with residents, personnel, visitors, government agencies/personnel, etc., under all conditions and circumstances

• Is subject to hostile and emotionally upset residents, family members, etc

• Communicates with the maintenance personnel, nursing staff, and other department supervisors

• Works beyond normal duty hours, on weekends, and in other positions temporarily, when necessary

• Is subject to call back during emergency conditions (e.g., severe weather, evacuation, post-disaster, etc.)

• Is subject to injury from falls, burns from equipment, odors, etc.throughout the workday, as well as reactions from dust, disinfectants, tobacco smoke, and other air contaminants

• Is subject to exposure to infectious waste, diseases, conditions, etc., including TB and the AIDS and Hepatitis B viruses

• May be subject to the handling of and exposure to hazardous chemicals

PHYSICAL AND SENSORY REQUIREMENTS

• Must be able to relate to and work with ill, disabled, elderly, emotionally upset, and at times hostile people within the facility

• Must meet the general health requirements set forth by the policies of this facility, which includes a mental and physical examination

• Must possess sight/hearing senses, or use prosthetics that will enable these senses to function adequately so that the requirements of this position can be fully met

• Must be able to push, pull, move, and /or lift a minimum of 25 pounds to a minimum height of 5 feet and be able to push, pull, move, and/or carry such weight a minimum distance of 50 feet

• May be necessary to assist in the evacuation of residents during emergency situations

OTHER:

• We are an Equal Opportunity Employer, Gender/Minority/Veterans/Disabled. 

• COVID VACCINE OR QUALIFYING EXEMPTION REQUIRED

It must be understood that this job description in no way states or implies that these are the only duties you will be required to perform.  The omission of specific statements of duties does not exclude them from the position if the work is similar, related or a logical assignment to the position.