Job Classification: Full-Time Regular

Purpose:

The Regional Director of Clinical Reimbursement (RDCR) is responsible for auditing and analyzing the MDS document for accuracy, planning and conducting training for CRC/CRS staff, Directors of Nursing and other key EHSI employees.  Partners with the clinical and financial teams to develop and enhance clinical reimbursement tools and systems.  Ensures that reimbursement structures are managed, evaluated and capture accurate resource utilization at the facility level.
  
REPORTING RELATIONSHIPS:


No direct reports
 


 


ESSENTIAL FUNCTIONS:


1.         Development - Identifies, tracks and reports clinical reimbursement trends to the ADCR, RDO, RDR, Area Controller.
2.         Development - Facilitates recruitment, orientation, evaluation and retention of CRC/CRS staff through the Administrator.
3.         Development - Facilitates communication with the ADCR, RDO, RDR and Field Analyst to enhance reimbursement outcomes.
4.         Development - Identifies, tracks and reports on managed care processes to the ADCR, RDO, RDR and Area Controller.
5.         Development - Participates in Mock survey assessment of facilities.
6.         Implementation - Conducts Medicare Validation Audits to assure accuracy of MDS coding and reimbursement.
7.         Implementation - Maintains relationships with case managers from the contracted managed care organization.
8.         Implementation - Conducts Managed Care Audits to assure compliance with the contract.
9.         Implementation - Participates in and/or conducts clinical reimbursement related calls.
10.       Implementation - Facilitates the interdisciplinary team development of action plan(s) to improve clinical reimbursement processes including:
�Validating accuracy of MDS data
�Reducing and eliminating MDS defaults
�Ensuring proper Medicare certification/recertification procedures are in place
�Monitoring Medicare length of stay
�Ensuring accurate case mix indices are assigned to residents
�Monitoring and enforcing corporate MDS submission guidelines
�Educating regarding selection of appropriate assessment reference dates
�Improving efficiency of interdisciplinary care planning process
�Partnering with the therapy program
�Evaluating and enhancing the restorative nursing program
�Evaluating and improving the admission process
�Partnering with Medicare Review to ensure that accurate ADR information is submitted to the fiscal intermediaries
�Assisting in the Medicare appeal process
�Reviewing Medicaid state audit results and implementing plans of corrections
11.       Education - Conducts RAI education and training as identified for CRC/CRS staff, interdisciplinary team members and other regional staff.
12.       Education -Conducts RUGs-based education and training as identified for CRC/CRS staff, interdisciplinary team members and other regional staff.
13.       Education - Collaborates with the ADCR and ADET to provide computer related education (i.e., CareTracker, PointRight).
 
Other Duties:


 
 
MINIMUM QUALIFICATIONS:


Education: Registered Nurse Licensure required.

 
Experience: One to three years previous experience as an MDS Coordinator or MDS Consultant.  Previous multi-facility management preferred.  Strong understanding of PPS Medicare Reimbursement and Case Mix Reimbursement a must.

 
Skills, Knowledge and Abilities: Strong computer related skills. Experience using computer systems and software including proficiency in Microsoft Office Word and an email system.
Strong oral and written communication skills.
Strong organizational and project management skills.
Ability to work with and train all levels of employees.
Ability to read, write, speak and understand English.
Demonstratable ability to lead and direct projects and project teams.
Flexibility to travel 70-80% of the time.
 
 
ENVIRONMENTAL AND PHYSICAL REQUIREMENTS:


Exposed to normal office environment and SNF clinical environments.
Position requires travel.   May be exposed to road and weather hazards. 
May be exposed to blood and body fluids therefore protective equipment must be worn as necessary.