Qureos Mentor

Alliance Health & Human Services

<div><p><b>ALLIANCE HEALTH MANAGEMENT SERVICES</b></p>
<p><b>
JOB DESCRIPTION AND PERFORMANCE APPRAISAL</b></p>
<p>STAFF NAME:_________________________________________ JOB TITLE: Regional Clinical Reimbursement Specialist</p>
<p>EMPLOYEE #:_____________ HIRE DATE:________________ APPRAISAL PERIOD:______________ TO ______________</p>
<p><b>POSITION PURPOSE:</b></p>
<ul><li>Assess and evaluate the quality of care being given to Alliance facility residents per CMS guidelines.</li></ul>
<ul><li>Oversees and Ensures completion of MDS interviews and assessments following the RAI process.</li></ul>
<ul><li>Ensuries regulatory compliance of Medicare, Medicaid, and Managed Care by following federal and state guidelines.
</li></ul><p><b>INTERPERSONAL RELATIONSHIPS:</b></p>
<ul><li>Coordinate with facility team to ensure implementation of the residents&rsquo; plan of care, assessments, and education.</li></ul>
<ul><li>Works with corporate team to ensure compliance, report any and all issues, and educate as needed.</li></ul>
<p><b>
EDUCATIONAL REQUIREMENTS:</b></p>
<ul><li>Graduate of an accredited School of Nursing (LPN, RN, or BSN). RN preferred.
</li></ul><p><b>PHYSICAL REQUIREMENTS:</b></p>
<ul><li>Physical health sufficient to meet the ergonomic standards and demands of the position and its location. Regular and consistent attendance at the facilities as needed.</li></ul>
<p><b>EXPERIENCE REQUIRED:</b></p>
<ul><li>Minimum 2 years clinical experience in a long-term care setting. Prior MDS/RAI experience</li></ul>
<ul><li>Demonstrated clinical assessment skills.</li></ul>
<ul><li>Knowledge of Medicare and Medicaid regulations and coverage guidelines related to skilled nursing.</li></ul>
<p><b>
SUPERVISORY RESPONSIBILITIES:</b></p>
<ul><li>Dotted line supervision of facility based MDS Coordinators</li></ul>
<p><b>
PROFESSIONAL LICENSURE AND CERTIFICATION REQUIRED:
</b></p><ul><li>Current/active Massachusetts Nursing license</li></ul>
<ul><li>RAC-CT certification preferred.</li></ul>
<ul><li>BLS CPR certification</li></ul>
<p><b>
REPORTING RELATIONSHIPS:</b></p>
<ul><li>Direct report to the Corporate Director for Clinical Reimbursement
</li></ul><ul><li>Dotted line relationships to:</li></ul>
<p>
o Corporate Director of Clinical Services</p>
<p>Issued by:______________________________________________</p>
<p>Approved by:___________________________________________</p>
<div><div><div><div><p>Review Date:____________________________________________</p></div></div><div><div><br>
</div></div><br>
<br>
</div></div><div></div><div><div><div><div><p>JOB DESCRIPTIONS/</p>
<p>
RESPONSIBILITY</p></div><div><br>
<p><b>
MDS COORDINATOR</b></p>
<p>PERFORMANCE INDICATORS</p></div><div><br>
<p>
MEASUREMENT CRITERIA/</p>
<p>
COMMENTS</p>
<p>
list specific examples for 1 - 5 ratings Key*</p></div><div><br>
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</div><br>
</div><div><div><div><p>Administrative Functions</p></div><div><br>
<ul><li>Serves as corporate lead for either short stay PDPM PPS MDS process or OBRA based long term care OBRA MDS (including MA based Medicaid PDPM based payment process).</li></ul>
<ul><li>Review the current AHMS Clinical Reimbursement (CR) Policies and Procedures for respective area, recommend modifications.
</li></ul><ul><li>Determine compliance with established policy. Develop and utilize a facility reporting process to ensure facility compliance with established policies. This includes both remote monitoring and onsite audits.</li></ul>
<ul><li>Evaluate current clinical reimbursement documentation forms and assessments to ensure facilities capture the care provided and maximize reimbursement.</li></ul>
<ul><li>Provide CR transition training to the organization to ensure that trainees gain functional knowledge, and the organization is prepared for the transition.
</li></ul><ul><li>Serve as a resource to CR staff for problem solving and real time education as needed for respective area.
</li></ul><ul><li>Ensure that all submissions are accurate, timely, and fully compliant with current rules and regulations.
</li></ul><ul><li>Conduct random audits of active and previously submitted MDS&rsquo;s.</li></ul>
<ul><li>Review Point Right data and make recommendations as needed.
</li></ul><ul><li>Review clinical documentation and make recommendations to improve as needed.
</li></ul><ul><li>Assist with end of month process.</li></ul>
<ul><li>Assist the other Lead as needed.</li></ul></div><div><br>
</div>
</div><br>
<div></div><div><div><p>Facility Support</p></div><div><br>
<ul><li>Evaluate current facility CR Nurses&rsquo; skills sets and provide observations, assessments, and recommendations.</li></ul>
<ul><li>Serve as a resource to CR staff for problem solving and real time education as needed.</li></ul>
<ul><li>Review and assist in all ARD requests from third party payers.</li></ul>
<ul><li>Conduct onsite audits and reviews of entire CR process. Conduct exit review with facility staff with findings and clear objectives.</li></ul>
<ul><li>Review and audit PASRR/NOMNC submissions</li></ul>
<ul><li>Review respiratory compliance and effectiveness.</li></ul>
<ul><li>Assist facilities with QM ratings objectives.</li></ul>
<ul><li>Participate in end of month activities as required.</li></ul>
<ul><li>Cover other regional&rsquo;s facilities as needed.</li></ul></div><div><br>
</div></div><br>
</div></div><div></div><div><div><div><div><p>Personnel Functions</p></div><div><br>
<ul><li>Follows work assignments, and/or work schedules to complete assigned tasks. Performs all assigned tasks in accordance with established policies and procedures.</li></ul>
<ul><li>Cooperates with interdepartmental personnel, as well as other departments within the facility to assure that services are properly maintained to meet the needs of the residents.</li></ul>
<ul><li>Develops and maintains a good working rapport with interdepartmental personnel.</li></ul></div></div></div></div></div><div></div>

Regional Clinical Reimbursement Specialist

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Alliance Health & Human Services

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Regional Clinical Reimbursement Specialist