Resident Care Coordination Specialist
2 weeks ago
Job Type
Full Time
Category
Nursing
Role Summary
The Care Management Specialist is accountable for overseeing the Resident Assessment Instrument (RAI) process, ensuring that resident evaluations are completed accurately and promptly in compliance with Medicare, Medicaid, OBRA, and other payer program standards. This role guarantees that assessments reflect the comprehensive physical, mental, and psychosocial condition of each resident, while also ensuring that proper documentation supports the services rendered and the accuracy of assessments. Effective communication with interdisciplinary team members is essential.
Key Responsibilities
- Guarantee timely and precise assessments of residents' health and functional conditions throughout the assessment period.
- Engage in the pre-admission process to collect vital information for MDS/Case Mix optimization from referral sources.
- Ensure the accurate and timely completion of all Medicare/Medicaid case-mix documentation to secure appropriate reimbursement for services rendered.
- Collaborate with the facility's Director of Rehabilitation to determine the most suitable assessment reference date (ARD) for Medicare/Managed Care assessments.
- Monitor Skilled (MRA/MCO/MCG/MMP) clients using Case Management Tools to verify ongoing Medicare/Managed Care eligibility and benefit periods through consistent communication with relevant parties.
- Collect necessary information for Managed Care Utilization Reviews during residents' stays and communicate with the Managed Care organization's Case Manager as needed.
- Ensure compliance with additional Medicare Program requirements, including physician certification and re-certification.
- Conduct concurrent MDS reviews to ensure the appropriate RUGs category is achieved through accurate clinical information capture.
- Participate in interdisciplinary team meetings to discuss opportunities and facilitate effective care plan development and management.
- Ensure the timely and accurate completion of all MDS assessments, including PPS, Unscheduled, Admission, Quarterly, Annual, and Significant Change assessments in accordance with RAI guidelines.
- Collaborate with the interdisciplinary team to identify significant changes in resident status and implement necessary adjustments to MDS.
- Maintain an organized schedule of all MDS assessments, ensuring proper reference dates throughout residents' stays.
- Track, document, and analyze all default days, implementing corrective actions as necessary.
- Conduct regular audits of the MDS process, validating coding documentation and evaluating outcomes per company policy.
- Ensure timely electronic submission of all Minimum Data Sets and arrange for backup personnel to complete this process.
- Review validation reports and ensure appropriate follow-up actions are taken.
- Analyze QM and SNF QRP reports monthly, ensuring necessary follow-up actions are executed.
- Communicate regularly with the Business Office Manager and Administrator regarding RUG distribution and its impact on reimbursement.
- Participate in various meetings as per company policy, assisting in the preparation and submission of any required documentation.
- Serve as a resource for RAI and Care Management to facility staff.
- Utilize annual competency training and educational resources as needed.
- Assist in orienting and training new associates on the RAI process and disseminating updated materials regarding RAI and regulatory changes.
- Manage daily operations of the department.
- Stay informed about reimbursement regulations.
- Organize and maintain data for easy retrieval.
- Adhere to personal hygiene and dress code standards.
- Maintain regular communication with the Regional Care Management Specialist regarding clinical reimbursement issues.
- Demonstrate flexibility in work hours to meet business needs.
- Utilize both local and corporate resources effectively in job execution.
- Exhibit superior clinical assessment and documentation skills.
- Demonstrate strong interpersonal skills and the ability to work collaboratively in a team environment.
- Perform other duties as assigned.
- Analytical reasoning
- Logical reasoning
- Problem-solving
- Time management
- Organizational skills
- Research capabilities
- Excellent verbal and written communication skills
Education and Training
- Graduate of an accredited nursing program with current R.N. or L.V.N. licensure.
- Completion of all required MDS/RUGs training modules within the first 90 days of employment.
- Proficiency in standard office software and MDS/RAI-related applications.
- Strong initiative and ability to lead interdisciplinary teams effectively.
- Valid licensure in the state of employment.
- Minimum of two years of healthcare experience.
- Experience with MDS completion, reimbursement, clinical resource utilization, and/or case management is preferred.
The physical demands outlined here are representative of those that must be met by an employee to successfully perform the essential functions of this role. Reasonable accommodations may be made to enable individuals with disabilities to perform these functions.
Regency Integrated Health Services is an Equal Opportunity Employer. The company does not discriminate based on race, religion, color, sex, gender identity, sexual orientation, age, disability status, national origin, veteran status, or any other legally protected status. All employment decisions are based on legitimate, non-discriminatory criteria.
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