Clinical Reimbursement Specialist

Avalon Health Care

8h•Hybrid

About The Position

Avalon Health Care Management, Inc. is seeking a confident leader to join us as Clinical Reimbursement Specialist! This is a full-time position with significant travel required. We offer great challenges, a rewarding career, and opportunities for advancement.

Requirements

Licensed RN
At least two years of experience working in a long-term care setting.
Knowledge and experience with Medicare technical and clinical coverage criteria, Prospective Payment System (PPS), and state Medicaid case mix requirements as applicable.
Must be available to travel frequently to facilities across the portfolio.
Must possess ability to effectively communicate with other health care professionals.
Must have adequate computer and keyboarding skills to allow use of electronic charting, billing and reporting systems.

Nice To Haves

Experience with RAI process and MDS certification preferred.

Responsibilities

Provides leadership, oversight and acts as a resource for regional and facility staff specific to the RAI process, the Medicare program, and Medicaid Case Mix as applicable.
Participates and contributes to the development of facility policies and procedures specific to clinical management systems related to the RAI.
Conducts regular monitoring of facility management systems for compliance with Avalon policies, procedures and best practices.
Works in coordination with the Regional Nurse Consultant to provide regional and facility interdisciplinary (IDT) teams with education and support for the development of systems to address and manage Quality Measures (QM) and the CMS Five Star Rating.
Supports accurate claims and billing.
Provides analysis and participates in regular reviews of facility clinical and financial outcome data.
Leads and participates in program improvement and development efforts related to the RAI, Medicare and Medicaid programs.
Conducts follow-up evaluations to validate that systems are functioning well after initial roll-out.
Participates in the Quality Assurance Process Improvement Program: Identifies and evaluates trends, Assists with Root Cause Analysis, Assists in identifying appropriate solutions, Supports facility follow-up through appropriate measurement design.
Participates during “mock survey” process with Regional Team as requested, and preparation for state and federal surveys as assigned.