Clinical Reimbursement Consultant RN

PruittHealth•Tallahassee, FL

About The Position

The Clinical Reimbursement Consultant RN coordinates training for center partners and audits processes, recommending improvements related to the RAI process, care management, supporting software, skilled Medicare services, and Medicare RUG, Medicaid Case Mix CMI, or Skilled Level of Care management. The role supports appropriate resident care and equitable, timely reimbursement through education, consultation, analysis, and process improvement. The consultant shares current and revised RAI, PPS, and Case Mix information with partners; reports on clinical and financial reimbursement status; and educates partners on the relationship between resident care, care planning, reimbursement, and applicable programs. The role provides guidance on MDS accuracy and compliance with company procedures and state and federal requirements, analyzes reports to identify trends and improvement opportunities, and supports troubleshooting of clinical software and billing systems. The position also interviews applicants for Case Mix Director / MDS Nurse roles and recommends candidates to the hiring authority, coordinates orientation for new CMDs, and supports privacy practices concerning residents’ protected health information. Frequent overnight travel may be required. Applicants need a current RN or Allied Health Professional license in the state where they practice and a bachelor’s degree in Nursing or another Allied Health discipline. Three years of clinical responsibility and RAI (MDS) experience are required; five years of health care management, MDS assessment, and care-planning experience in multi-facility long-term care organizations is preferred.

Requirements

Current, active license as a Registered Nurse or Allied Health Professional in the state where practicing.
Bachelor’s degree from an accredited school of Nursing or other Allied Health Care institution.
At least three years of clinical responsibility and experience with the RAI process (MDS).
Knowledge of state and federal clinical and financial regulations related to the RAI process and reimbursement systems.
Microsoft proficiency is required.

Nice To Haves

Credential Nurse Assessment Coordinator preferred.
Five years of health care management, MDS assessment, and care-planning experience in multi-facility long-term care organizations preferred.
Experience with MatrixCare and/or Pointright.

Responsibilities

Distribute current, new, and revised RAI, PPS, and Case Mix information to appropriate partners in a timely manner.
Provide regional and corporate staff with information on clinical and financial reimbursement status.
Participate in national and state professional organizations that strengthen the company’s knowledge and position concerning RAI, Case Mix, and clinical software programs.
Educate center partners on the importance and use of the RAI and Care Plan, Medicare PPS, State Case Mix, and Skilled Level of Care processes and their relationship to resident care and reimbursement.
Instruct partners on reading, interpreting, and using state, federal, and company reports.
Provide expertise, consultation, and guidance to support MDS accuracy and adherence to company policies, procedures, and state and federal regulations and guidelines, based on audits and other available data.
Analyze financial and clinical reports to identify trends and improvement areas and ensure an appropriate process-improvement plan is completed.
Maintain in-depth knowledge of clinical software, billing systems, the RAI process, and company online support to investigate and troubleshoot user-related software issues.
Interview applicants for Case Mix Director / MDS Nurse positions and provide recommendations to the hiring authority.
Oversee and coordinate thorough, timely orientation for new CMDs.
Adhere to and oversee communication of privacy guidelines concerning residents’ protected health information.
Participate in process-improvement activities as appropriate.
Travel overnight when required.