Clinical Reimbursement Specialist - MDS
ProMedica`s senior care division, formerly known as HCR ManorCare, operates 335+ assisted living facilities, skilled nursing centers, memory care communities and hospice and home health care agencies. Services are provided in 26 states and currently operate under the brand names Heartland, ManorCare, ProMedica and Arden Courts. Over the next 18 months, the senior care entities will begin to rebrand to ProMedica.
Driven by its Mission to improve your health and well-being, ProMedica has been nationally recognized for its advocacy programs and efforts to address and lead in social determinants of health, champion healthy aging and cultivate innovative solutions. For more information about ProMedica senior care services, please visit www.promedicaseniorcare.org.
The Clinical Reimbursement Specialist is responsible to review Medicare/Medicaid documentation to assist nursing centers in completing MDS to ensure appropriate levels of Medicare and/or Medicaid reimbursement. Works with RDOs, Administrators, and facility staff in training/consulting on traditional Medicare A coverage, documentation, and eligibility. As part of a regional team (MRBS, RRM, CMS), assists with monitoring medical records requests for M2 and Managed Medicaid payers to ensure they are tracked and responded to in a timely manner. This role will cover skilled nursing facilities in the Washington and Colorado regions and candidates must live in that area.
- Monitors that facilities follow Medicare/Medicaid regulatory and HCR ManorCare guidelines.
- Remains abreast of regulatory change for Medicare/Medicaid reimbursement and communicates necessary information to appropriate personnel.
- Reviews MDS documentation for accuracy and appropriateness
- Monitors and assists with validation of Quality Measures report for accuracy of MDS coding.
- Assists with developing and presenting training materials for MDS training sessions. .
- Participates in interviews of DCD and MDS Coordinators.
- Performs audits per company standards and policies to ensure appropriate levels of reimbursement.
- Monitors Corporate Compliance policies and notifies appropriate facility, regional, divisional, and corporate staff as needed.
- Collaborates with corporate and/or facility staff related to denial issues affected by the MDS.
- Collaborates with the facility to keep them informed of new developments for Federal and State payment systems.
- Coaches facility ADNS, Administrators, and other staff as to proper procedures for M2 medical records requests, and Part A ADRs and Appeals.
- Makes recommendations regarding eligibility and coverage for Medicare Part A.
- Monitors M2 (Medicare, Managed Care) and Managed Medicaid records requests, with the regional team, to ensure they are tracked and responded to in a timely manner.
Graduate of an approved Registered Nurse program and RN licensed in the state of practice required.
Minimum of 2 years of nursing experience in a Skilled Nursing Facility preferred. Excellent knowledge of Case-Mix, the Federal Medicare PPS process, and Medicaid reimbursement, as required. Thorough understanding of the Quality Indicator process. Knowledge of the OBRA regulations and Minimum Data Set. Knowledge of the care planning process.
Nursing - Management
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