MDS Reimbursement Director

Job Summary:

The MDS Director of Reimbursement is responsible for overseeing Clinical Reimbursement initiatives for the company. Manage and evaluate clinical reimbursement staff in the company. Track, trend and identify arears of improvement as well as opportunities for growth. Ensure that reimbursement structures are managed, evaluated, and capture accurate resource utilization at all the facilities levels. Partner with the Clinical, Financial and Rehab teams to develop and enhance clinical reimbursement tools and systems.

Essential Duties and Responsibilities:

• Develop and implements case management and clinical reimbursement programs.
• Review weekly/monthly RUG distribution/reimbursement reports. assist in identification of trends
• Provide instruction to the Facility MDS Coordinators on the RAI Processes and Systems.
• Track, trend and analyze current RUG scores. end splits. CMI on a weekly and monthly basis and report to the management team.
• Assist the VP of Clinical Services in developing a plan of action to improve the clinical reimbursement / RAJ functions and processes at the Facilities level.
• Serve as the subject matter expert for the Company on all areas related to Clinical Reimbursement and RAI.
• Serve as the Corporate Liaison with V. P. of Rehab, reviewing RUGs utilization, Forecasts, ADL Index and Reimbursement Utilization.
• Collaborate with the Company Chief Compliance Officer to ensure adherence to company’s policies and procedures plus Federal and State Regulations.
• Partner with Medical Review to ensure that accurate ADR information is submitted to the fiscal intermediaries.
• Maintain Current information on OBRA regulations, licensure requirements, and other regulatory and agency standards.
• Assesses the knowledge, skills, techniques, procedure and performance of the nursing MDS and staff as it relates to coding of the MDS and related assessments.
• Trains the MDS staff on the appropriate CAAs and trigger worksheets and assessment reference dates.
• Serves as the subject matter expert for the company on all areas related to clinical reimbursement.
• Assist in identification development and implementation of education opportunities.
• Routinely visits facilities to review, monitor and audit the quality of coding to reflect nursing care provided to residents.
• Coordinate with other functional executives and managers to properly scope projects, coordinate their execution across functions and develop training and educational programs as required. Manage change control.
• Participate in the recruitment, evaluation and retention of MDS Staff.

Qualifications :

• RN/Therapist or completion of a Bachelor’s Degree in a Health Care or related field, consistent with the duties to be performed.
• Five to Ten years of Clinical Reimbursement or MOS experience.
• Current knowledge of computer technology and systems.
• Extensive knowledge of MOS and back-up documentation required and extensive knowledge of state grouper and calculator field relative to MOS and state payment.
• Extensive knowledge of Medicare reimbursement, RUG IV systems, compliance and edibility.
• Strong project management skills with a record of successful project execution. Competence in computer technology and systems needed to manage Medicare/State Case Mix systems.
• Five years’ .experience in Long Term Care Management .
• Communicate effectively with staff, doctors, and corporate leadership, utilizing diplomacy and discretion.
• Travel to other facilities required.