Clinical Reimbursement Specialist

Balance Life & Work with a New Career Opportunity

(LONG TERM CARE)

(SHORT TERM REHAB)

(SKILLED NURSING)

(ASSISTED LIVING)

(LTACH)

(SUB ACUTE CARE)

Now Hiring - Clinical Reimbursement Specialist - Fort Lee, NJ 07024

The Clinical Reimbursement Specialist assures the implementation of company policies and procedures pertaining to the Medicare and Managed care reimbursement in the facility. This position reports to the Administrator of the facility and receives consultative assistance from the Regional Clinical Reimbursement Specialist. The Clinical Reimbursement Specialist is also responsible for regulatory compliance and quality improvement efforts in order to attain appropriate Medicare or Managed Care reimbursement. This position integrates information from all necessary disciplines to maintain accuracy and compliance with the MDS process. By conducting concurrent MDS reviews, he/she assures the achievement of maximum allowable RUG categories. Working collaboratively with facility team members, the Specialist ensures that services offered meet or exceed federal, state and company standards and serves as a role model for ethical business practices according to health standards.

Essential Duties and Responsibilities:

1. Maintain a professional standard of behavior when interacting with staff, residents family members or visitors
2. Follow and uphold the company Code of Conduct
3. Facilitate Daily PPS and Weekly Medicare meeting
4. Knowledge of and compliance with HIPAA guidelines
5. Knowledge of and ability to download reports from Point Right
6. Knowledge of and ability to download state and federal reports from Internet
7. Participate in Monthly Billing Reconciliation meeting
8. Complete MDS's per schedule as required for Medicare, Managed care and OBRA schedules
9. Initiate/Update Care plans as required
10. Ensure compliance with State, Federal, and Point Right transmissions and make modifications as needed
11. Facilitate and coordinate with other disciplines to maintain care plan development and ongoing updates per MDS schedule
12. Provide updates as required per Managed Care contract guidelines
13. Communicate promptly with facility team/regional consultant any issues or concerns
14. Completion and issuance of denial letters, coordination of Medicare certification completion, review of skilled nursing documentation (including CNA documentation) to support skilled needs
15. Serve as the center resource for MDS/PPS; and state Medicaid reimbursement.
16. Manage Medicare appeals process, and participate in Administrative Law Judge hearings as needed.
17. Implement and participate in the company processes developed to appropriately maximize reimbursement
18. Attend additional meetings; perform other duties as assigned

Position Requirements:

• Graduate of an approved RN program
• Current RN license in the state and credentials as required
• Prior experience in Medicare reimbursement and/or MDS experience preferred
• Knowledge of Managed Care reimbursement systems
• Word processing and computer skills
• Excellent oral and written communication skills
• Excellent ability to maintain an effective, friendly working relationship with others
• Basic mathematic ability; ability to use calculator
• Knowledge of quality improvement process, how it affects the 5 Star report, and ability to identify issues or trends and implement corrective action plans as needed
• Excellent attention to detail; well organized
• Ability to provide one-on-one or small group education related to identified areas of need