Care Management Specialist

4 weeks ago

Brownsville, 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. This is a full-time position responsible for coordinating the Resident Assessment Instrument (RAI) process to ensure accurate and timely completion of resident assessments in accordance with Medicare, Medicaid, OBRA, and other payer program requirements.

Key Responsibilities
  • Ensure timely, accurate, and complete assessment of the resident's health and functional status during the entire assessment period.
  • 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.
  • Collaborate 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.
  • 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 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 RIHS 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. licensure.
  • Complete and pass all RIHS 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.
Regency Integrated Health Services is an Equal Opportunity Employer

Regency does not discriminate on the basis of race, religion, color, sex, gender identity, sexual orientation, age, disability status, national origin, veteran status, or any other basis covered by appropriate law.

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