Registered Nurse - Clinical Reimbursement Director (MDS)
Lakeland Hills Center

Job DetailsCompany Overview

The Clinical Reimbursement Director is responsible for assisting Resident Assessment Instrument (RAI) process to ensure accurate and timely completion of resident assessments in accordance with Medicare, Medicaid, OBRA and other payor program requirements.

ESSENTIAL DUTIES AND RESPONSIBILITIES:

Case Management

• Manages Medicare Part A and Part B certification process.

• Performs ongoing evaluations from pre-admission through discharge to ensure an appropriate reimbursement level for each resident. Evaluates care to ensure that services and products match benefits available

• Reviews medical records, care plans, charting to ensure documentation supports care provided and reimbursement level.

• Monitors facility practice to ensure compliance with guidelines for participation in Medicare, Medicaid and other benefit programs. Initiates action needed to ensure compliance.

• Participates in quad check prior to release of claims. Tracks and reviews all claim denials to identify problems.

• Assists in preparation and timely submission of any additional development requests, reconsiderations and administrative law judge hearings.

• Review state MDS validation reports to identify issues and or processes to ensure accuracy of submitted MDS's.

• Responsible for evaluating and providing education, intervention and support for Medicare, PPS, RAI, state specific and special contract reimbursement.

• Manage the overall process of reimbursement for the facility.

• Track all Medicare/Medicaid case-mix documents in order to assure appropriate reimbursement for services provided within the facility.

• Other duties as assigned

RAI Process

• Initiates and completes discharge and re-entry tracking forms accurately and timely.

• Performs modifications of assessments in accordance with CMS Correction Policy.

• Verifies timely transmission of MDS assessments, including tracking forms to the State in accordance with standards.

• Other duties as assigned

SUPERVISORY RESPONSIBILITIES:

• There are no supervisory responsibilities for this position.

Recommended Skills

• Medicare
• Case Management
• Medicaid
• Communication
• Assessments
• Computer Literacy

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