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Clinical Reimbursement Consultant - Coastal North

PruittHealth Raleigh, NC Full-Time
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Coordinates thetraining of center partners and audits and provides recommendation for ProcessImprovement for the following areas:
• The RAI Process, the Care ManagementProcess, and the use of various supporting software applications to ensure anappropriate level of Resident care and equitable and timely reimbursement ofthe care provided.
• Utilization of skilled Medicareservices
• Medicare RUG, Medicaid Case Mix CMI/ or Skilled Level of Care management

• Ensures current, new, and revisedRAI / PPS / Case Mix information is distributed to appropriate partners in atimely manner.
• Provides information to regional andcorporate staff on the status of clinical and financial reimbursement.
• Participates in national and stateprofessional organizations that strengthen the company’s position and knowledgeof the RAI process, Case Mix and clinical software programs.
• Provides information and educationto center partners on the importance and use of the RAI and Care Plan, MedicarePPS, and State Case Mix and Skilled Level of Care processes and theircorrelation to resident care and reimbursement.
• Provides instruction on how to read,interpret and use the information contained in various state, federal, andcompany initiated and generated reports.
• Provides expertise, consultation andguidance to appropriate partners to ensure MDS accuracy and adherence tocompany policy and procedures, as well as state and federal regulations andguidelines based on information derived from audits and other available data.
• Identifies trends and areas ofimprovement and ensures an appropriate PI plan is completed, through analysisof financial and clinical reports.
• Maintains in-depth knowledge of theclinical software and billing system, the RAI process, and company initiatedonline support to help investigate and troubleshoot user-related softwareissues.
• Interviews applicants for the CaseMix Director / MDS Nurse and provides recommendations to the hiring authority.
• Oversees and coordinates the processfor a thorough and timely orientation for new CMDs.

• Adheres to and overseescommunication of privacy guidelines relative to the confidentiality ofresidents’ protected health information.
• Participates in PI activities asappropriate
• Frequent overnight travel may berequired.

• Knowledge of state and federalregulations, both clinical and financial as it relates to the RAI process andreimbursement systems.
• Current Licensed Registered Nurse orAllied Health Care Professional in state of residence. Credential NurseAssessment Coordinator preferred.
• Microsoft required
• Experience in MatrixCare, Pointrighta plus


Bachelors’ degree froman accredited school of Nursing or other Allied Health Care Institution

Five- (5) years health care management,MDS Assessment & care Planning experience in multi-facility, long-term careorganizations preferred.

Three (3) years clinical responsibility andexperience with RAI process (MDS) required

Current, active licenseas a Registered Nurse or Allied Health Professional in the State practicing.

ADDITIONAL QUALIFICATIONS: (Preferred qualifications)
Software: MatrixCareand/or Pointright

Job: Administrative
Primary Location: North Carolina-Raleigh
Schedule: Full-time
Shift: 1st Shift
Job Posting: Jan 30, 2020, 9:19:45 AM

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Job ID: 1911092


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