Full-Time Regional Clinical Reimbursement Specialist
NOTE: This job listing has expired and may no longer be relevant!
Avalon Health Care Hale Nani, is seeking a Regional Clinical Reimbursement Specialist in Hawaii to join our team!
The Clinical Reimbursement Specialist (CRS) is responsible for education and oversight of the Resident Assessment Instrument (RAI) process in facilities as assigned. The CRS supports the development of programs and business management systems that promote accuracy of the RAI and as a result accurate reimbursement for services provided.
Essential Job Functions:
- Provides leadership, oversight and acts as a resource for regional and facility staff specific to the RAI process, the Medicare program, and Medicaid Case Mix as applicable.
- Provides education and training to regional and facility personnel specific to the RAI, Medicare, and Medicaid as applicable.
- Provides orientation and education to regional and facility staff related to the RAI, Medicare, Medicaid and reimbursement related topics as assigned.
- Conducts regular facility visits and may conduct conference calls/webinars with regional and facility personnel to perform essential job duties.
- Participates and contributes to the development of facility policies and procedures specific to clinical management systems related to the RAI.
- Participates and contributes to the development of facility clinical and business management systems related to the RAI and skilled service payer sources.
- Promotes accurate capture of the burden of care, through review and education of the Resource Utilization Group (RUGs) RUGS classification systems as applicable to the Medicare and Medicaid programs.
- Conducts regular monitoring of facility management systems for compliance with Avalon policies, procedures and best practices.
- Conducts/participates in audits of facility practices as directed by Avalon Compliance Officer.
- Supports accurate and timely submission of clinical information requested by medical review entities (e.g., Medicare Administrative Contractors (MAC), Recovery Audit Contractors (RAC), Comprehensive Error Rate Testing (CERT), Probes etc.).
- Works in coordination with the Regional Nurse Consultant to provide regional and facility interdisciplinary (IDT) teams with education and support for the development of systems to address and manage Quality Measures (QM) and the CMS Five Star Rating.
- Conducts periodic review of facility management systems and documentation specific to the RAI, Medicare and Medicaid, as applicable.
- Supports accurate claims and billing.
- Supports appeals management of denied claims.
- Provides analysis and participates in regular reviews of facility clinical and financial outcome data.
- Leads and participates in program improvement and development efforts related to the RAI, Medicare and Medicaid programs.
- Participates and supports facility staff during transitions to new health information systems.
- Conducts follow-up evaluations to validate that systems are functioning well after initial roll out.
- Participates in the Quality Assurance Process Improvement Program:
- Identifies and evaluates trends
- Assists with Root Cause Analysis
- Assists in identifying appropriate solutions
- Supports facility follow-up through appropriate measurement design
- Participates during “mock survey” process with Regional Team as requested, and preparation for state and federal surveys as assigned.
- Provides subject matter expertise and support for facility response to survey results (e.g., IDR, 2567)
- Licensed RN or Licensed Therapist (PT, OT or SLP)
- At least two years of experience working in a long-term care setting.
- Experience with RAI process and MDS certification preferred.
- Knowledge and experience with Medicare technical and clinical coverage criteria, Prospective Payment System (PPS), and state Medicaid case mix requirements as applicable.
- Must possess ability to effectively communicate with other health care professionals.
- Must have adequate computer and keyboarding skills to allow use of electronic charting, billing and reporting systems
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