Clinical Reimbursement Specialist

3 weeks ago

Livingston, California, United States CareOne Full time
Clinical Reimbursement Coordinator Job Description

The Clinical Reimbursement Coordinator plays a vital role in ensuring the implementation of company policies and procedures related to Medicare and Managed care reimbursement in our facility. This position reports to the Administrator and receives consultative assistance from the Regional Clinical Reimbursement Specialist.

Key Responsibilities:
  • Maintain a professional standard of behavior when interacting with staff, residents, family members, or visitors.
  • Follow and uphold the company Code of Conduct.
  • Facilitate Daily PPS and Weekly Medicare meetings.
  • Knowledge of and compliance with HIPAA guidelines.
  • Knowledge of and ability to download reports from Point Right.
  • Knowledge of and ability to download state and federal reports from the Internet.
  • Participate in Monthly Billing Reconciliation meetings.
  • Complete MDS's per schedule as required for Medicare, Managed care, and OBRA schedules.
  • Initiate/Update Care plans as required.
  • Ensure compliance with State, Federal, and Point Right transmissions and make modifications as needed.
  • Facilitate and coordinate with other disciplines to maintain care plan development and ongoing updates per MDS schedule.
  • Provide updates as required per Managed Care contract guidelines.
  • Communicate promptly with facility team/regional consultant any issues or concerns.
  • Completion and issuance of denial letters, coordination of Medicare certification completion, review of skilled nursing documentation (including CNA documentation) to support skilled needs.
  • Serve as the center resource for MDS/PPS; and state Medicaid reimbursement.
  • Manage Medicare appeals process, and participate in Administrative Law Judge hearings as needed.
  • Implement and participate in the company processes developed to appropriately maximize reimbursement.
Requirements:
  • Graduate of an approved RN program.
  • Current RN license in the state and credentials as required.
  • Prior experience in Medicare reimbursement and/or MDS experience preferred.
  • Knowledge of Managed Care reimbursement systems.
  • Word processing and computer skills.
  • Excellent oral and written communication skills.
  • Excellent ability to maintain an effective, friendly working relationship with others.
  • Basic mathematic ability; ability to use calculator.
  • Knowledge of quality improvement process, how it affects the 5 Star report, and ability to identify issues or trends and implement corrective action plans as needed.
  • Knowledge of the 5 Star report.
  • Excellent attention to detail; well organized.
  • Ability to provide one-on-one or small group education related to identified areas of need.

About CareOne:

CareOne is committed to defining excellence within the healthcare community. We strive to provide a framework of strength and stability for our Centers and Communities. We work to maintain the highest standards of care and service for Residents, families, and our valued employees.

We offer a competitive salary, comprehensive healthcare benefits, 401k retirement plan, paid time off, opportunities to advance and grow your career, and more.

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