REGIONAL CLINICAL REIMBURSEMENT SPECIALIST

RiseMe; Dallas (TX); On-site; USD 85,000 - 120,000; Full time

Job summary

INNOVATIVE NURSE CONSULTING LLC seeks a Regional Clinical Reimbursement Specialist to travel daily for regional facility support, lead clinical reimbursement planning, and ensure regulatory compliance. You will oversee MDS program administration under the Director of Clinical Reimbursement and coordinate care management activities across regions.

The role requires a nursing degree and RN licensure, with experience in MDS coding, regulatory requirements, and reimbursement processes.

Qualifications

• Analytical approach to synthesize complex information
• Ability to identify and resolve problems in a timely manner
• Clear and effective written and verbal communication
• Attention to detail and commitment to quality
• Demonstrates integrity and professional ethics
• Follows policies, procedures, and supports organizational goals
• Reliability in meeting deadlines and commitments

Responsibilities

• Review medical records to determine required documentation
• Conduct nursing review of patient records for regulatory compliance
• Prioritize tasks to meet deadlines in a production setting
• Develop appeal arguments using clinical evidence and regulations
• Support MDS program oversight and care management operations
• Protect resident information and report suspected breaches
• Attend mandatory training and in-service programs

Skills

Analytical

Problem Solving

Communication

Quality

Integrity

Organizational Skills

Dependability

Education

Nursing degree

RN licensure

Job description

Job Details: Job Location: INNOVATIVE NURSE CONSULTING LLC - DALLAS, TX, Salary Range: Undisclosed, Job Shift: Any, Regional Clinical Reimbursement Specialist

As a Regional Clinical Reimbursement Specialist, you will travel daily to facilities in your Region to promote, plan, organize, develop, coordinate, and direct our facility teams in support of Clinical Reimbursement in accordance with State and federal regulatory requirements and our company's established policies and procedures to assure that the highest degree of quality resident care and safety be maintained. You will work under the direction of the Director of Clinical Reimbursement and be responsible for the executive oversight of the administration, clinical planning, development, and operations of the MDS program. This position supports regional and facility employees in all aspects of care management.

ESSENTIAL DUTIES AND RESPONSIBILITIES:

Medical records review utilizing clinical and regulatory knowledge to determine required supporting documentation. Clinical nursing review of patient records for compliance with facility practices and procedures as directed. Flexibly manage tasks to meet deadlines by re-prioritizing workflows in a production-oriented setting. Employ critical thinking to identify / resolve issues and provide timely feedback regarding medical review processes. Develop appeal arguments using clinical evidence, supporting references / regulations, and participate in appeal hearings by providing testimony, as required. Determine regulatory and clinical support for appeal arguments when pre-existing resources are unavailable. Proficiently review and synthesize abstract information from handwritten / electronic medical records to support claims. Agree not to disclose assigned user ID code and password for accessing resident / facility information and promptly report suspected or known violations of such disclosure to the Director of Medical Records. Agree not to disclose resident's protected health information and promptly report suspected or known violations of such disclosure to the Director of Medical Records. Report any known or suspected unauthorized attempt to access facility's information system to Director of Medical Records. Attend and participate in mandatory in-service training programs, workshops, seminars, etc., as approved / delegated.

Qualifications:

EDUCATION:

Must be a graduate of an accredited school of nursing, currently registered with a state agency for nursing licensure, and hold a valid license in the state he/she is employed.

QUALIFICATIONS/EXPERIENCE:

Experience in geriatric / long-term care nursing documentation, Minimum Data Set (MDS) coding, and/or medical necessity reviews / appeals. Working knowledge of regulatory and payer requirements for reimbursement and reason(s) for denial of claims for Medicare, Medicare Advantage, or Medicaid. Completion of continuing education on subjects related to case management, regulatory requirements, restorative nursing, medical records documentation, legal aspects of documentation, reimbursement, and compliance.

SKILLS/COMPETENCIES:

• Analytical - Synthesizes complex or diverse information using experience and judgement to complement data
• Problem Solving - Identifies / resolves problems in a timely manner; develops solutions; works well in group problem solving situations
• Communication - Speaks / writes clearly and informatively; listens and gets clarification; responds well to questions; demonstrates group presentation skills, edits work for spelling and grammar; varies writing style to meet needs
• Quality - Demonstrates accuracy and thoroughness; excellent attention to detail with a critical eye to catch / correct mistakes and errors; applies feedback to improve performance; monitors own work to ensure quality
• Character - Demonstrates integrity in every aspect of work and dealing with others; consistently models desired behaviors and values established by the company; respects diversity of perspective in discussions and demonstrates an inclusive style; demonstrates concerns for job safety for self and others
• Organizational Support - Follows policies and procedures; completes administrative tasks correctly and on time; supports organization's goals and values
• Dependability - Follows instructions and responds to management direction; takes responsibility for own actions; keeps commitments and completes tasks on time or notifies appropriate person with an alternate plan