Clinical Reimbursement Consultant RN

PruittHealth • Tallahassee, FL

7d • Remote

About The Position

This role coordinates the training of center partners and conducts audits, providing recommendations for process improvement in areas such as the RAI Process, the Care Management Process, and the use of supporting software applications. The goal is to ensure an appropriate level of resident care and equitable, timely reimbursement. The position also focuses on the utilization of skilled Medicare services and Medicare RUG, Medicaid Case Mix CMI, or Skilled Level of Care management.

Requirements

• Knowledge of state and federal regulations, both clinical and financial as it relates to the RAI process and reimbursement systems.
• Current Licensed Registered Nurse or Allied Health Care Professional in state of residence.
• Microsoft required
• Three (3) years clinical responsibility and experience with RAI process (MDS) required.

Nice To Haves

• Credential Nurse Assessment Coordinator preferred.
• Experience in MatrixCare, Pointright a plus
• Five- (5) years health care management, MDS Assessment & care Planning experience in multi-facility, long-term care organizations preferred.
• Software: MatrixCare and/or Pointright

Responsibilities

• Ensures current, new, and revised RAI / PPS / Case Mix information is distributed to appropriate partners in a timely manner.
• Provides information to regional and corporate staff on the status of clinical and financial reimbursement.
• Participates in national and state professional organizations that strengthen the company’s position and knowledge of the RAI process, Case Mix and clinical software programs.
• Provides information and education to center partners on the importance and use of the RAI and Care Plan, Medicare PPS, and State Case Mix and Skilled Level of Care processes and their correlation to resident care and reimbursement.
• Provides instruction on how to read, interpret and use the information contained in various state, federal, and company initiated and generated reports.
• Provides expertise, consultation and guidance to appropriate partners to ensure MDS accuracy and adherence to company policy and procedures, as well as state and federal regulations and guidelines based on information derived from audits and other available data.
• Identifies trends and areas of improvement and ensures an appropriate PI plan is completed, through analysis of financial and clinical reports.
• Maintains in-depth knowledge of the clinical software and billing system, the RAI process, and company initiated online support to help investigate and troubleshoot user-related software issues.
• Interviews applicants for the Case Mix Director / MDS Nurse and provides recommendations to the hiring authority.
• Oversees and coordinates the process for a thorough and timely orientation for new CMDs.
• Adheres to and oversees communication of privacy guidelines relative to the confidentiality of residents’ protected health information.
• Participates in PI activities as appropriate.

Benefits

• As an Equal Employment Opportunity employer, all qualified applicants will receive consideration without regard to race, color, religion, sex, national origin, disability, or veteran status.

What This Job Offers

• Job Type: Full-time
• Career Level: Manager