Reimbursement Services Director - Home Care jobs in Worcester, MA

The Regional Director of Clinical Reimbursement Services is responsible for the overall operational systems that involve clinical reimbursement for PDPM, Case management, CT and MA specific Case-Mix/ and MA MMQ. This role ensures that highest quality of clinical reimbursement services in accordance with all applicable laws, regulations and Center standards.

This role will acts a liaison with patients, family, support departments, etc. to adequately plan for patient needs. Participate in establishment of departmental budgetary standards and management. In addition, the Director of clinical reimbursement services will directly support the MDS Nurse Case Managers, Case Mix Nurses and will provide orientation, mentoring and training.

Additionally, the Regional Director of Clinical Reimbursement Services will support centers’ Clinical Reimbursement department in an advisory role in personnel management including approval of time off, coverage plans, performance appraisals and competencies and hiring/terminating of staff. As the Director of Clinical Reimbursement, they will be delegated the responsibility and accountability necessary for carrying out your assigned duties.

About the Company

Ascentria Care Alliance employees and volunteers take pride in the impact they have on the people they serve. It’s more than just a job, it’s an opportunity our employees have to care for and share in the lives of people who greatly need and appreciate their presence. Ascentria Care Alliance focuses on every child, elder, person with a differing ability, refugee, teenage mom – and whomever they call “family” - in order to build stronger communities one person at a time, ensuring that they experience New England as home to caring communities where people experience love, belonging, wellbeing, and hope. This is an excellent opportunity to help shape the impact of a $150 M non-profit social services organization with programs throughout New England.

Essential Job functions: Responsibility and standards:

• This role provides collaborative leadership and acts as a liaison between the clinical reimbursement and other clinical departments.
• Oversee clinical reimbursement accuracy of MDS coding, care planning and skilled clinical documentation. Reviews clinical documentation, skilled processes and accuracy of skilled reimbursement.
• Act as an educator, trainer, auditor and advisor to the clinical reimbursement teams including MDS nurse, case management, Case-Mix nurses, and other clinical departments as designated. Provide training to the MDS nurse, case manager, case mix nurse and pertinent Center staff with up to date regulatory and compliance standards of practice.
• Research other training methods, materials to assist in ensuring that the quality and appropriateness of patient care are in compliance with state, federal, legal, regulatory, accreditation, and reimbursement guidelines.
• Supports centers with weekly MDS Case Management meetings and overall clinical operation meeting regarding staffing, census/ALOS, skilled caseload management, and other designated topics. Attends and provide recommendations during weekly utilization review meetings.
• Utilize Clinical and Therapy Software Program to monitor, manage the clinical reimbursement outcomes including performance of nursing and therapy metrics to function at established center focused clinical targets but not limited to: billing efficiency, productivity, length of stay management, and skilled coding accuracy.
• Review and monitor all skilled financial reports on a routine basis, implements action plans and monitors for potential areas of improvement. Support team to conduct timely completion of claims triple check, claims review and provide follow up and or recommendation for compliance of billing.

Clinical Quality and Performance:

•  Directly responsible for leading the Clinical Reimbursement teams for ensuring that the quality and appropriateness of patient care meets or exceeds company and industry standards and ensures that all Clinical reimbursement services are in compliance with state and federal legal, regulatory, accreditation and reimbursement guidelines.
• Manages, coordinates and monitors Quality Measures, Quality Reporting and CASPER /QIES reporting including routine schedule reviews of QM packets, QRP reporting and Center specific Center reporting including but not limited to:
  • Missing assessment report,
  • Resident roster report,
  • Provider preview report.

• Provide education and support IDT collaboration of team review of CASPER report, education and train on interpretation of data, conduct retrospective and proactive review of quality measure, quality reporting program and VBP. 
• Directly responsible for compliance of clinical reimbursement including timely completion of audits and reviews. Responsible for supporting Center based follow up after review/audit findings from Quality Assurance, Compliance, and consultation reviews.  Collaborates with centers to ensure follow through of internal and external audits that affect these areas.
• Monitor MDS Completion and Transmission of Assessments and conduct clinical reviews to support MDS accuracy and pertinent PDPM Deep Dive information. Provide support to the designated skilled nursing centers in PDPM deep dive and oversee follow up of clinical review to support accuracy of skilled services pertinent to Medicare, Managed care and other skilled and nonskilled payers. 
• Support Center leaders to conduct departmental performance evaluations and competencies in accordance with established policies and procedure in accordance with the centers guidelines, which is its Human Resource Guideline.
• Maintains confidentiality of all pertinent patient/resident care information to ensure that patient/resident’s rights are protected.
• Exhibits courtesy, compassion and respect to patients, families, visitors, physician’s administrators and co-workers.
• Monitors customer satisfaction and promptly responds to complaints. Promotes positive customer relations.
• Adheres to, keeps current with, and reviews policies and procedures as outlines in the Clinical Reimbursement policy and procedures manual and Rehabilitation department manual as necessary.
• Other: tasks or duties as assigned by the Senior Chief Executive Officer and other designated leadership team members as needed.

Knowledge, Skills, Experience Required

• Associates Degree, Bachelor’s Degree, or Master’s Degree in Nursing, Physical Therapy, Occupational Therapy or Speech-Language Pathology.
• Current professional licensure in the state of hire.
• Two to four years of clinical experience, and one to two years of supervisory experience with multi SNF centered preferred. Background in In house Therapy, Case Management, Clinical Reimbursement of Medicare, Managed Care, Veterans Affairs, Case Mix, MMQ and other designated skilled reimbursement.
• Demonstrated ability to function independently
• Possess strong oral and written communication skills. Organizational and analytical skills required.
• Ability to function effectively in multi-faceted systems and to interact effectively with all levels of staff and customers.

Benefits

• Medical Insurance
• Dental Insurance
• Vision Insurance
• FSA and dependent care account
• 3 Weeks PTO and 9 Holidays!
• Tuition Assistance
• And many more!

Ascentria Care Alliance celebrates diversity and is proud to be an Equal Opportunity Employer. In compliance with federal and state employment opportunity laws, qualified applicants are considered for all positions without regard to race, color, religion, sex, national origin, age, physical or mental disability, genetic information, pregnancy, status as a veteran, sexual orientation, gender expression or identity, or any other legally-protected category. Candidates who identify as BIPOC, multilingual or have lived experience with immigration or human services are encouraged to apply.