Regional Clinical Reimbursement Specialist

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

Job summary

ALLIANCE HEALTH MANAGEMENT SERVICES seeks a Regional Clinical Reimbursement Specialist to oversee MDS/RAI processes, ensure CMS guideline compliance, and coordinate with facility teams for accurate reimbursement in long-term care settings.

The role requires a MA nursing license, 2+ years of LTAC experience, and RAC-CT preferred, with strong regulatory knowledge and collaboration across corporate and facility levels.

Qualifications

• Minimum 2 years clinical experience in a long-term care setting.
• Prior MDS/RAI experience.
• Knowledge of Medicare and Medicaid regulations and coverage guidelines related to skilled nursing.

Responsibilities

• Review current CR Policies and Procedures; ensure compliance with policy.
• Evaluate and audit MDS submissions and documentation for accuracy and timeliness.
• Coordinate with CR staff for problem solving and real-time education as needed.
• Lead short stay PDPM PPS MDS process or OBRA-based MDS processes.
• Assist with end-of-month processes and ARD requests from third-party payers.
• Provide CR transition training and support to the organization.

Skills

Clinical assessment

MDS/RAI experience

Medicare/Medicaid regs

Regulatory compliance

Education

RN

BSN

LPN

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:____________________________________________