Clinical Reimbursement & Quality Management

St. Catherine of Siena Nursing and Rehabilitation and St. Catherine of Siena Hospital are proud members of Catholic Health and have served the residents of the Smithtown area for more than 50 years. St. Catherine's is located on the north shore of Long Island in Smithtown. The campus is comprised of a 240-bed nursing and rehabilitation care center; 296-bed not-for-profit community hospital and a 60,000 square foot medical office building. Our nurses, physicians and support staff are devoted to providing advanced health care in an environment of compassion to our patients, their families and our community. Our Mission is to create an environment of healing and compassion, to offer care to those in need and to provide a spirit of mutual respect while upholding our religious mission.

We are dedicated to providing a supportive environment, committed to the highest standards of patient care, where health care professionals can develop their expertise and strengthen their credentials. Our primary focus is the way we treat and serve our communities. We work collaboratively to provide compassionate care and utilize evidence based practice to improve outcomes – to every resident and patient, every time.

Job Details

Clinical Reimbursement & Quality Management Responsibilities

Summary: The Clinical Reimbursement and Quality Management plays a vital role in ensuring accurate reimbursement for services provided to residents, while simultaneously improving the quality of care and ensuring compliance with regulatory standards. 

Key Responsibilities:

Clinical Reimbursement:

• Documentation: Review and analyze resident documentation to ensure accuracy and completeness for reimbursement purposes, including Minimum Data Set (MDS) assessments and other relevant documentation. 
• Coding and Billing: Assist in the accurate coding and billing of resident care services to maximize reimbursement. 
• Claim Review: Review and analyze submitted claims for accuracy and identify potential areas for improvement or appeal. 
• Regulatory Compliance: Stay up-to-date on current reimbursement regulations and guidelines (e.g., Medicare, Medicaid) and ensure compliance. 
• Data Analysis: Analyze reimbursement data to identify trends and opportunities for improvement in care and documentation practices. 
• Quality Management:
• Quality Improvement: Participate in the development and implementation of quality improvement initiatives to enhance resident care and outcomes. 
• Data Collection and Analysis: Collect, analyze, and report on quality data to identify areas for improvement and track performance. 
• Performance Improvement Projects: Lead or participate in quality improvement projects to address specific issues or concerns. 
• Policy and Procedure Development: Assist in the development and implementation of policies and procedures related to quality and reimbursement. 
• Regulatory Compliance: Ensure compliance with relevant regulations and standards related to quality of care and resident safety. 
• Documentation: Review and ensure the accuracy and completeness of resident records, including assessments, care plans, and progress notes. 
• Communication: Serve as a liaison between nursing staff, residents, families, and other healthcare professionals to ensure effective communication and coordination of care. 
• Other Responsibilities:
• Training: Provide training to staff on documentation, coding, billing, and quality improvement processes. 
• Audits: Assist with internal and external audits related to quality and reimbursement. 
• Problem Solving: Identify and resolve issues related to reimbursement and quality of care

Qualifications:

• Education: Bachelor of Science in Nursing (BSN) or related field preferred. 

        Certification as a PRI Assessor preferred.

        Successful completion of a MDS training course.

• Experience: Minimum 1 year MDS experience and a minimum of 2-3 years of clinical nursing experience, with experience in long-term care or related healthcare setting preferred. 
• Knowledge: Strong understanding of nursing care, documentation, coding, billing, and reimbursement regulations. 
• Skills: Excellent communication, interpersonal, and organizational skills. 
• Other: Ability to work independently and as part of a team, attention to detail, and ability to prioritize tasks. 

This range serves as a good faith estimate and actual pay will encompass a number of factors, including a candidate’s qualifications, skills, competencies and experience. The salary range or rate listed does not include any bonuses/incentive, differential pay or other forms of compensation that may be applicable to this job and it does not include the value of benefits.

At Catholic Health, we believe in a people-first approach. In addition to the estimated base pay provided, Catholic Health offers generous benefits packages, generous tuition assistance, a defined benefit pension plan, and a culture that supports professional and educational growth.

Salary : $115,000 - $135,000