Regional Clinical Reimbursement Specialist

Alliance-Health-; Southborough (MA); On-site; USD 90,000 - 120,000; Full time

Job summary

ALLIANCE HEALTH MANAGEMENT SERVICES in Massachusetts seeks a Regional Clinical Reimbursement Specialist to oversee MDS interviews, ensure CMS-guided care quality, and maintain regulatory compliance for Medicare, Medicaid, and managed care programs. This role coordinates with facility teams and corporate partners to implement plans of care and education.

The position requires nursing licensure in Massachusetts, 2+ years in long-term care, and MDS/RAI experience.

Qualifications

• 2+ years clinical experience in long-term care
• Prior MDS/RAI experience required
• Knowledge of Medicare/Medicaid regulations for skilled nursing

Responsibilities

• Oversee and ensure completion of MDS interviews and assessments per RAI process.
• Assess and evaluate quality of care per CMS guidelines.
• Ensure regulatory compliance with federal and state guidelines for Medicare/Medicaid/Managed Care
• Coordinate with facility and corporate teams to implement plans of care and educate staff
• Provide CR transition training and act as a resource for problem solving

Skills

Clinical experience

MDS/RAI experience

Medicare/Medicaid knowledge

Regulatory compliance

Education

Nursing license MA

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

Issued by:______________________________________________

Approved by:___________________________________________

Review Date:____________________________________________

JOB DESCRIPTIONS/ RESPONSIBILITY

MDS COORDINATOR

PERFORMANCE INDICATORS

MEASUREMENT CRITERIA/ COMMENTS

list specific examples for 1 - 5 ratings Key*

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.