Lead Clinical Nurse Reimbursement Specialist

Friendly Senior Living•Rochester, NY

8h•$82,410 - $101,649•Onsite

About The Position

The Lead Clinical Nurse Reimbursement Specialist organizes and directs the clinical reimbursement programs to optimize reimbursement for The Friendly Home. The role oversees the Clinical Reimbursement Department and its staff, coordinates assessment and reimbursement processes, and works with the interdisciplinary team (IDT) to ensure accurate, timely documentation, coding, billing, and regulatory compliance. The specialist also monitors quality measures, supports audits and appeals, provides staff training, and serves as a clinical liaison to health plans. The position is based in a clean, well-lit, home-like nursing home setting. The employee must be able to perform the essential job functions, subject to reasonable accommodation, meet the employer’s general health requirements, and may be asked to assist with evacuations or other emergency procedures. Employees are expected to report on time, work their scheduled shifts, and work overtime and weekends when required by the position or approved by management.

Requirements

Current New York State registration and license.
Experience in long-term health care.
Current experience with MDS 3.0, RUGS reimbursement methodology, Medicare reimbursement regulations, and the prospective payment system.
Excellent communication skills.
Dependable attendance, punctuality, and ability to work scheduled shifts.
Willingness and ability to work overtime and weekends as required by the position or approved by management.
Reliable transportation to and from work.
Clean and neat appearance and a friendly, service-oriented personality.
Ability to comply with work procedures and organizational policies.
Ability to perform essential job functions, subject to reasonable accommodation, and meet the employer’s general health requirements.
May be required to assist with member evacuation or other emergency safety procedures.

Nice To Haves

R.N. or B.S.N. education preferred.

Responsibilities

Coordinate the RAI process and schedule required OBRA and PPS assessments for assigned residents in accordance with state and federal regulations; ensure the IDT follows the schedule.
Manage the overall operations of the Clinical Reimbursement Department, including supervision of Clinical Nurse Reimbursement Specialists and MDS per-diem staff.
Oversee quality performance measures, monitor their accuracy and optimization, and review MDS documentation and care plans to identify trends and quality-improvement opportunities.
Facilitate Medicare, CMI, and Grand Rounds meetings to communicate pertinent information to the IDT and support reimbursement optimization and accurate, timely billing.
Evaluate Medicare eligibility and continued coverage for new admissions and readmissions using current criteria.
Review PDPM MDS assessments with the IDT to ensure appropriate and timely documentation and accurate coding and scoring.
Oversee Medicaid-only case mix management for compliance and reimbursement optimization.
Identify and ensure availability of supporting documentation from internal and external sources to optimize reimbursement.
Review Medicare A MDS 3.0 assessments for content accuracy and appropriate RUGS codes before submission.
Review Medicaid MDS 3.0 assessments for appropriate and accurate documentation before submission.
Track therapy minutes for Medicare compliance, arrange appropriate MDS assessments, and communicate with the finance department.
Assess IDT staff competency in compliance and reimbursement documentation and processes, and collaborate with the Nurse Educator to provide education.
Train new staff on completing MDS assessments in Health MedX.
Track new admissions who may qualify for Medicare but lack skilled needs during their first 30 days, to identify possible eligibility.
Inform Nurse Managers when a member is covered by Medicare and explain why, ensuring necessary supporting documentation is available.
Investigate and correct findings identified by the Medicare consultant.
Oversee and assist with payment-related external audits.
Stay current with changes to MDS, RUGS, PDPM, CMI, and Medicare reimbursement systems.
Serve as clinical liaison for HMOs and communicate with HMOs and Medicare Advantage plans to ensure documentation and updates are completed.
Manage Medicare A and B appeals.
Obtain authorization numbers for Medicare B members receiving skilled therapy.
Perform other duties as assigned and comply with HIPAA regulations.