Clinical Reimbursement Specialist (MDS)
Regents Park of Winter Park

Job DetailsCompany Overview

The Clinical Reimbursement Director is responsible for the

coordination of the "Resident Assessment Instrument" process to ensure accurate and timely

completion of resident assessments in accordance with Medicare, Medicaid, OBRA and other

payor program requirements.

ESSENTIAL DUTIES AND RESPONSIBILITIES:

Case Management

• Manages Medicare Part A certification process.

• Performs ongoing evaluations from pre-admission through discharge to ensure an

appropriate reimbursement level for each resident. Evaluates care to ensure that services

and products match benefits available

• Reviews medical records, care plans, charting to ensure documentation supports care

provided and reimbursement level.

• Monitors facility practice to ensure compliance with guidelines for participation in

Medicare, Medicaid and other benefit programs. Initiates action needed to ensure

compliance.

• Participates in quad check prior to release of claims. Tracks and reviews all claim denials

to identify problems.

• Assists in preparation and timely submission of any additional development requests,

reconsiderations and administrative law judge hearings.

• Review state MDS validation reports to identify issues and or processes to ensure

accuracy of submitted MDS's.

• Responsible for evaluating and providing education, intervention and support for

Medicare, PPS, RAI, state specific and special contract reimbursement.

• Manage the overall process of reimbursement for the facility.

• Track all Medicare/Medicaid case-mix documents in order to assure appropriate

reimbursement for services provided within the facility.

• Other duties as assigned.

RAI Process

• Participates in the pre-admission process to ensure essential information needed for

MDS/Case mix optimization is obtained from the referral source.

• Works in collaboration with Rehab Program Coordinator to ensure the most appropriate

assessment reference date is utilized for assessments.

• Lead and manage Clinical Reimbursement Specialist(s) in a matrix Management

environment.

• Performs modifications of assessments in accordance with CMS Correction Policy.• Other duties as assigned.

Recommended Skills

• Medicare
• Case Management
• Medicaid
• Communication
• Assessments
• Computer Literacy

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