Clinical Reimbursement Specialist

2 weeks ago


Zeeland, Michigan, United States SKLD Zeeland Full time

Job Overview:

We are seeking a highly skilled Clinical Reimbursement Specialist to join our team at SKLD Zeeland. In this critical role, you will play a vital part in ensuring the accurate reimbursement for Medicare and PDPM/PPS Case Managed residents.

About the Job:

The Nurse Assessment Coordinator (NAC) is responsible for providing leadership in the management of the Minimum Data Set (MDS) and utilization management process in accordance with current federal, state, and local standards.

Key Responsibilities:

  • Stay up-to-date with current federal and state regulations, as well as professional standards, to ensure compliance.
  • Ensure all OBRA tracking forms and assessments are scheduled per RAI guidelines to maintain accurate data.
  • Review Medicare A (Managed Care if utilizing PDPM) admissions to confirm necessary referral records are obtained, and provide comprehensive care to the resident.
  • Assign primary ICD-10 code for all Medicare A and Managed Care residents using PDPM.
  • Schedule all necessary Medicare and Managed Care MDS assessments required for reimbursement per CMS and managed care guidelines.
  • Collaborate with the NAC team to ensure timely completion of assessments, utilizing MDS resources appropriately according to the center's assessment schedule.
  • Transmit assessments per CMS guidelines, reviewing validation reports, warnings, and rejections.
  • Identify TSI analytic alerts indicating potential MDS coding, Care Area, or Reimbursement concerns and address them with the Clinical team.
  • Conduct Quality of life meetings to establish OBRA schedules, review Quality Measures, resident goals, and key metrics to maintain a resident's highest practicable level.
  • Attend weekly UR meetings to lead discussions on skilled residents with Med A and B payer sources, facilitating determination of continued skilled level of care and medical necessity per Medicare guidelines.
  • Communicate with IDT regarding clinical needs or changes.
  • Conduct monthly Triple Check meetings.
  • Assist in guiding the MDS Coordinator and IDT to ensure MDS coding and supportive documentation accurately represent the resident and meet regulatory and auditor requirements.
  • Participate in QAPI processes related to accurate coding, clinical reimbursement, and compliance, maintaining established infection control and standard precaution practices when providing care.
  • Maintain strict confidentiality regarding sensitive health information of Residents.
  • Report hazardous conditions, damaged equipment, and supply issues to appropriate persons.
  • Maintain a high level of confidentiality in accordance with HIPAA guidelines at all times and protect confidential information by only providing information on a need-to-know basis.
  • Communicate and interact effectively and tactfully with Residents, visitors, families, peers, and supervisors.
  • Attend staff meetings and in-services as requested, attending continuing education programs and required training for maintenance of professional certification or licensure.
  • Understand Infection Control principles and follow the Company's Infection Control guidelines, recognizing signs and symptoms of infection and maintaining personal hygiene.
  • Promote and Protect Resident Rights by assisting Residents to make informed decisions, treating Residents with dignity and respect, protecting Residents' personal belongings, reporting suspected abuse or neglect, avoiding physical restraints in accordance with current professional standards, and supporting independent expression, choice, and decision-making consistent with applicable laws and regulations.

Requirements:

Education, Training, and Experience:

  • Current State License as a Registered Nurse.
  • CPR Certified.
  • Knowledge and training in all aspects of the MDS process.
  • One year of experience as an RN in a long-term care setting.

Specific Skills, Knowledge, and Abilities:

  • Effectively communicate with the IDT by mentoring and evaluating the activities and performance of the RAI Process.
  • Knowledge of current federal and state laws and regulations that apply to the practice of nursing in a long-term care setting.
  • Strong organizational and time management skills, with the ability to prioritize responsibilities.
  • Ability to apply mathematical concepts such as fractions, percentages, ratios, and proportions to practical situations.
  • Basic computer knowledge is required.

Salary: $62,000 - $72,000 per year

Benefits: Health insurance, 401(k) matching, paid time off, and opportunities for professional growth and development.



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