RN
: Job Details :

DEPARTMENT: MDS

POSITION: RESIDENT CLINICAL REIMBURSEMENT SPECIALIST (MDS Coordinator)

SUPERVISOR: Administrator

POSITION SUMMARY: Coordinates and monitors Medicare, Managed Care and Medicaid revenue at the facility. Ensures residents receive optimal skilled services to meet needs for optimal independent function and potential discharge to the community including management of the MDS process and serving as liaison for insurance companies. Monitors facility Quality Measures, identifies issues related to Quality Measures and assists facility with any corrective actions needed to improve overall quality services. Educates Administrator and facility staff on innovative procedures to optimize utilization and reimbursement through the completion of the MDS, care plan and care guide process.

ESSENTIAL POSITION FUNCTIONS: 1. Education – Provides education and assistance to facilities on Medicare/Medicaid related areas including eligibility, certification, coverage, documentation, utilization and reimbursement. Assists facilities with initial certification procedures and follow-up of problem areas. Updates policies and procedures to reflect current changes. 2. Coordination – Interacts with Medicare, Managed Care and Medicaid claims review unit and compliance unit to assist facilities in complying with company procedures and federal, state and local regulations. Reports regularly to administration on issues and activities. Interacts with the Medicare and managed Care intermediary in professional areas of coverage and documentation. Assists in review and preparation of denied claims or administrative record reviews by outside intermediaries. Responsible to coordinate weekly Insurance/Medicare Meeting for the purpose of evaluating resident progress and ongoing skilled service's needs. 3. Monitoring –Completes and assess compliance with Medicare, Managed Care and Medicaid and third party payers and company procedures. Establishes systems and programs designed to correct any non-compliance situation. Participates with any outside reimbursement audits to acquire first hand knowledge of areas that might lead to system failures. 4. Administration – Establishes and maintains current statistical data associated with the Medicare, Managed Care and Medicaid programs by region. Cooperates with operations to monitor activities for contractor programs, i.e. therapies, utilization review. Reviews and maintains Medicare, Managed Care and Medicaid reference materials. 5. Financial Management – Monitors and identifies utilization issues. Establishes systems and programs to maximize utilization and reimbursement. Establishes system to identify rehabilitation training needs, to provide training and recommendations to enhance therapy utilization. Monitors compliance with third party policies and procedures for authorizations for payment and provision of services. 6. Training – Provides ongoing orientation and training to appropriate facility staff regarding the Medicare, Managed Care and Medicaid and other contracted third party payers. Programs. Provides education regarding changes in any program. 7. Meetings – Coordinates, facilitates and attends meetings. 8. Committees – Attends and participates in committees as assigned. 9. Staff Development – Attends and participates in training and other learning activities at the facility level. 10. Gathers data and gives direction to acquire accurate and timely completion of MDS 3.0 as it relates to Medicare, Managed Care and Medicaid. Monitors, coordinates and enhances the completion of the MDS and the interdisciplinary team members in a professional manner. 11. Makes ones self available for Regional visits to acquire knowledge and discuss any on-going issues at the facility level as it relates to the accurate and timely completion of the MDS. 12. Is the chair person for the care plan meeting and conducts those meetings in a thorough manner capturing the accurate information revealed through the completion of the MDS. 13. Audits adl logs and assessments etc. to ensure that information is accurate and timely in completing the MDS assessment tool. 14. All other duties as assigned. 15. Communicates and observes the Corporate Compliance Program effectively and complies with Code of Conduct when performing work functions.

SUMMARY OF QUALIFICATIONS: Able to perform each of the essential position functions. 1. A Registered Nurse or Licensed Practical Nurse in the State of Ohio 2. Prefer two year's experience in Medicare/Medicaid areas in long-term care or clinical training. 3. Must have excellent communication and teaching skills in both individual and group settings. 4. Must be capable of maintaining regular attendance and be available to travel including overnight travel as required. 5. Must be capable of performing all of the essential job functions of this position, with or without reasonable accommodations. 6. Possess working knowledge of MDS 3.0, care plans, care guides and the CMI reimbursement process.