TheRegional Clinical Reimbursement Specialistis directly responsible for the management of theMDS RAI process,Medicaid Case Mix,Medicare/PDPMandManaged Caresystems across 5 centers to ensure appropriate reimbursement in accordance with all applicable laws and regulations.

Skills, Knowledge, Experience:

• Oversee MDS coding accuracy across all disciplines, including the care plan process
• Reviews clinical documentation, skilled processes and accuracy of skilled reimbursement to support accurate claims and billing, and adherence to company’s Triple Check Process.
• Monitor MDS Completion and Transmission of MDS assessments and conduct clinical reviews to support MDS accuracy and pertinent PDPM/Case Mix qualifier accuracy
• ICD-10 Coding for accuracy and reimbursement
• Serves as a resource to facility teams in Medicare, Medicaid, ACO and Managed Care/Commercial plans to capture clinical complexity that supports favorable clinical and financial outcomes
• Act as an educator, trainer, auditor and advisor to the clinical reimbursement teams and pertinent facility staff with up to date regulatory and compliance standards of practice.
• Will support centers’ Clinical Reimbursement departments in an advisory role in personnel management including approval of time off, coverage plans, performance appraisals, competencies, and hiring/terminating of staff.
• Engages facility management team in problem solving to identify improvement opportunities and achieve solutions
• Facilitate effective, well organized utilization meetings, establish productive objectives and follow through with action plans
• Works collaboratively with Regional Clinical, Operations and Quality Assurance team to provide regional and facility interdisciplinary teams with education and support for the development of systems to address and manage Quality Measures, CMS Five Star Rating, VBP and QRP data. Manages, coordinates and collaborates review with interdisciplinary team members on the above data elements.
• Directly responsible for compliance of clinical reimbursement, including timely completion of internal/external audits and reviews.
• Supports centers through DPH survey, plans of correction, and Case Mix Audits.

Knowledge, Skills, Experience Required:

• Current license as a Registered Nurse issued by the State Board of Nursing. (Will consider LPN with extensive RAI and regional level experience)
• Minimum 5 years’ experience with the RAI process
• Prior multi facility experience preferred
• Possess strong oral and written communication skills. Organizational and analytical skills required.
• Ability to function effectively in multi-faceted systems and to interact effectively with all levels of staff and customers.
• Self-directed, able to take initiative and follow through to achieve desired outcomes.
• Strong attention to detail and accuracy with ability to multi task and prioritize during times of high volume.
• Must be flexible and able to work effectively with others
• Point Click Care, Net Health, Microsoft Word, Excel and Power Point a plus!

We offer competitive compensation based on experience.

Note: This job description is intended to provide a general overview of the position. It is not an exhaustive list of all responsibilities, duties, skills, or qualifications required.