Care Management Specialist

6 days ago

Houston, Texas, United States Regency Integrated Health Services Full time
Job Summary

We are seeking a highly skilled Care Management Specialist to join our team at Regency Integrated Health Services. As a Care Management Specialist, you will play a critical role in ensuring the accurate and timely completion of resident assessments, as well as coordinating the Resident Assessment Instrument (RAI) process.

Key Responsibilities
  • Coordinate the RAI process to ensure accurate and timely completion of resident assessments in accordance with Medicare, Medicaid, OBRA, and other payer program requirements.
  • Ensure assessments accurately reflect the physical, mental, and psychosocial status of each resident.
  • Communicate effectively with other members of the interdisciplinary team.
  • Follow all Regency Integrated Health Services policies and procedures.
  • Participate in the pre-admission process to ensure essential information needed for MDS/Case Mix optimization is obtained from the referral source(s).
  • Ensure accurate and timely completion of all Medicare/Medicaid case-mix documents to assure appropriate reimbursement for services provided within the facility.
  • Work in collaboration with the facility Director of Rehab to ensure the most appropriate assessment reference date (ARD) is utilized for Medicare/Managed Care Assessments.
  • Track Skilled (MRA/MCO/MCG/MMP) customers utilizing Case Management Tools to determine continued and appropriate Medicare/Managed Care eligibility and benefit period through regular communications with Regional Care Management Specialist, Business Office, and external Case Managers.
  • Gather information needed for Managed Care Utilization Reviews throughout the resident's stay and communicate this with the Managed Care organization's Case Manager as required.
  • Ensure that additional requirements of the Medicare Program are met, such as Physician certification and re-certification.
  • Perform concurrent MDS review to assure appropriate RUGs category is achieved through the capture of appropriate clinical information.
  • Participate in the interdisciplinary team process to communicate opportunities, facilitate efficient and effective care plan development and management.
  • Ensure the accurate and timely completion of all MDS assessments, including PPS, Unscheduled, Admission, Quarterly, Annual, and Significant Change in compliance with RAI guidelines.
  • Collaborate with the interdisciplinary team to identify significant change in status and implementation of Significant Change in Status MDS.
  • Maintain an accurate schedule of all MDS assessments to include the proper reference dates throughout the resident's stay.
  • Track, record, and analyze all default days and rectify if appropriate. Implement corrective action to prevent further default action.
  • Perform Modification/Inactivation of assessments in accordance with CMS Correction Policy and collaboration with Regional Care Management Specialist.
  • Conduct regular audit of MDS process, including validation of coding documentation, evaluating outcomes, and utilization of Data Integrity Audit reports (Point Right) per company policy.
  • Ensure the timely electronic submission of all Minimum Data Sets and secure back-up personnel to complete this process.
  • Review the Validation reports and ensure that appropriate follow-up action is taken.
  • Review Late/Missed assessment reports monthly and address issues as appropriate.
  • Review QM and SNF QRP reports monthly and ensure that appropriate follow-up action is taken.
  • Communicate with the Business Office Manager and Administrator on a regular basis regarding RUG distribution, default days/unassigned days, case mix index (if applicable), and their reimbursement impact.
  • Participate in daily Case Management, weekly Level of Care, monthly Triple Check, and other meetings per Regency Integrated Health Services policy.
  • Assist in the preparation and timely submission of any Additional Development Requests (ADRs), Reconsideration, and Administrative Law Judge (ALJ).
  • Function as an RAI and Care Management resource to the facility staff.
  • Utilize AIS as annual competency training as well as for educational resource as needed.
  • Assist in the orientation and training of new associates on the RAI process and ensure the dissemination of any new or updated materials regarding the RAI and/or Federal and State regulations.
Requirements
  • Must be a graduate of an accredited school of nursing with current R.N. or L.V.N.
  • Position may be filled by LVN, however specific job functions denoted by will require an RN to Coordinate the process as stipulated by Federal Regulations.
  • Complete and pass all Regency Integrated Health Services specific MDS/RUGs training modules (AIS) within the first 90 days of employment and ongoing per company policy.
  • Competency with standard office software applications as well as software applications related to MDS/RAI processes.
  • High initiative and ability to efficiently and effectively lead interdisciplinary teams and coordinate and manage RAI process.
  • Licensure in the state in which employment occurs.
  • Minimum of two years health care experience.
  • Experience with MDS completion, reimbursement, clinical resource utilization, and/or case management is highly desirable.

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