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Lead Clinical Nurse Reimbursement Specialist

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!

Position Summary:

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:

• 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.