What are the responsibilities and job description for the Lead Clinical Nurse Reimbursement Specialist position at Friendly Senior Living?
Friendly Senior Living is a highly rated Senior Care Community, - we embrace and live our values every day: Friendship, Teamwork, Compassion, Excellence, Integrity, and Customer Focus. Because Friends Care Always!
We consider many different factors to determine your compensation package at FSL. We assess your specific job family, level, relevant skills, experience, and other special trainings, or accomplishments you bring to the position. Pay decisions are also guided by our financial means as well as analyzed against what others earn internally. We strive to pay competitively and offer market differentiated benefits and perquisites in line with our compensation philosophy. The salary range is a reflection of many similar like positions and your actual compensation may not be at the high or low end of the range but will be based on your unique skills and other criteria mentioned. FSL is committed to offering each individual an elevated employee experience through growth and learning opportunities in addition to an inclusive work culture coupled with other perquisites.
Position Summary
Position Summary
Every effort has been made to identify the essential functions of the Lead Clinical Nurse Reimbursement Specialist position. The Lead Clinical Nurse Reimbursement Specialist organizes and directs the clinical reimbursement programs with the goal of optimizing reimbursement for The Friendly Home.
Essential Job Functions:
- Oversees the coordination of the RAI process, schedule all OBRA required and PPS assessments for all assigned residents according to state and federal regulations; and ensure that the IDT adheres to the schedule.
- Responsible for overall operations of Clinical Reimbursement Department, including supervision of Clinical Nurse Reimbursement Specialist and MDS Per Diem staff.
- Oversees Quality Performance Measures; monitors and manages Quality Measures for accuracy and optimization; performs chart reviews on MDS and care plans as necessary to identify patterns/trends and opportunities for Quality Improvement.
- Facilitates effective meetings (Medicare, CMI, Grand Rounds) to ensure thorough communication of pertinent information to IDT and maintain a strong team approach to optimizing reimbursement, and ensure compliance with accurate and timely billing.
- Evaluates and determines Medicare and continued Medicare coverage for both new admissions and readmissions, utilizing current criteria.
- In conjunction with IDT reviews all PDPM MDSs for appropriate and timely documentation and coding to ensure compliance and accuracy in scoring.
- Oversees the management of the Medicaid only case mix to ensure compliance and optimization.
- Identifies and assures the availability of supporting documentation that will optimize reimbursement from both internal and external (hospitals, outpatient facilities, etc.) sources.
- Reviews all Medicare A MDS's 3.0 for content accuracy and appropriate RUGS’s codes prior to submission.
- Reviews all Medicaid MDS’s 3.0 for appropriate and accurate documentation prior to submission.
- Tracks therapy minutes to comply with Medicare guidelines communicate and set up appropriate MDS’s and communicate to finance department.
- Continual oversight and assessment of IDT staff competency related to compliance and reimbursement documentation, process, and requirements; collaborates with Nurse Educator to provide education to ensure compliance.
- Provides training to new staff on MDS completion in Health MedX.
- Tracks new admissions that are technically eligible for Medicare, but do not have skilled needs for the first thirty days following admission, to identify possible eligibility.
- Communicates to Nurse Managers when a Member is Medicare covered and why to ensure necessary supporting documentation.
- Responsible to investigate and correct findings by the Medicare consultant.
- Oversee and assist with all payment related external audits
- Stays abreast of changes in any MDS, RUGS, PDPM, CMI, and Medicare reimbursement systems.
- Serves as Clinical Liaison for HMO’s and Communicate to HMO’s/Medicare Advantage ensures that documentation and updates are completed.
- Manages all appeals for Medicare A & B.
- Obtains all authorization numbers for Medicare B Members for skilled therapy.
- May be required to perform other duties as assigned.
- Complies with HIPPA regulations.
- Demonstrates excellent communication skills.
Other Job Functions:
Expectations of the Position:
Expectations of the Position:
- Dependable, report to work on-time for every schedule shift (ready to work at beginning - start of shift) and work full schedule shifts unless physically unable or pre-approved Paid Time Off (PTO) which includes personal and vacation.
- Willing and able to work overtime and weekends as required by the position and/or approved by management.
- Have reliable transportation to and from work.
- Must be clean and neat in appearance and have a “friendly” service-oriented personality.
- Abide by work-related / job procedures and organization policies; (refer to the Employee Handbook).
Qualifications of the Position:
- Education: R.N./B.S.N. preferred.
- Experience: Experienced in Long Term Health Care, as well as current experience in MDS 3.0, RUGS reimbursement methodology, Medicare reimbursement regulations and prospective payment system.
- Skills:
- Licenses / Certifications: Current New York State Registration and License.
Conditions of Employment:
- Work is performed in a clean, well lit, “Home-Like,” nursing Home setting.
- Employee must be able to perform essential job functions (reasonable accommodation may apply).
Physical Requirements
- Refer to Physical Requirements form.
- Must meet the general health requirements set forth by Friendly Home.
- May be requested to assist in the evacuation of Members or perform other procedures to protect the safety of Members, visitors and team members during emergency situations.
NOTE: This job description is not intended to be all-inclusive and very effort has been made to identify the essential functions of the above position. However, this job description in no way states or implies that the duties specifically identified are the only duties required to perform this position. The omission of specific statements of duties does not exclude them from the position if the work is similar, related, or is an essential function of the position. Employees may perform other related duties within Federal and/or State regulations to meet the ongoing needs of the organization. This job description is not a guarantee of employment for any set period and that either the organization or employee may terminate employment at any time with or without case. Furthermore, this job description may be added to or revised at any time.
I understand that above job duties and also understand that if I have any questions regarding my job responsibilities I should see my supervisor immediately.
