About this opportunity
Alliance Health & Human Services lists this Regional Clinical Reimbursement Specialist opportunity in southborough, Massachusetts. Review the employer’s description below for duties, qualifications and application requirements.
Job description
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:
Corporate Director of Clinical Services
JOB DESCRIPTIONS/ RESPONSIBILITY
list specific examples for 1 - 5 ratings Key*
MDS COORDINATOR
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.
Issued by:
Approved by:
Review Date:
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Who can apply
Review the original listing for work authorization, qualifications and employer requirements.