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