Director, Clinical Reimbursement

				Overview:

The Director of Clinical Reimbursement is responsible for overseeing the MDS departments at Schulman & Schachne Institute for Nursing and Rehabilitation and Rutland Nursing Home, ongoing review and management of clinical service revenue streams at both nursing facilities. The Director establishes and maintains an in-depth understanding of all clinical programs that impact reimbursement. Strategically and collaboratively, the Director develops structures to maximize clinical services revenue streams in accordance with all rules and regulations that apply to the business. 

Responsibilities:

* Understands Medicaid and Medicare case mix processes, RUGS categories, and other clinical reimbursement opportunities.
* Provides education on MDS guidelines and PPS requirements to staff.
* Maintains continuous learning and working knowledge of key reimbursement regulations and policies. 
* Shares industry standards with leadership teams.
* Translates regulatory and policy developments into meaningful guidance to internal processes.   
* Establishes metrics and goals for process and outcome measures that impact on and result in successful reimbursement. 
* Develops and maintains an organizational structure for review and audit of clinical reimbursement methodologies and outcomes including, but not limited to, trends in reimbursement and payer denial rates and relationships to clinical documentation; implements improvement strategies as indicated.
* Monitors, consults, and makes effective recommendations for changes and modifications to existing facility processes, systems, policies, and practices which will assure efficient, effective and compliant state Medicaid/Medicare/Managed Care payment performance.
* Chairs triple-check meeting prior to Medicare/Medicare HMO billing process.
* Provides monthly reports / dashboards on reimbursement trends and outcomes.
* Monitors managed care authorization process, determinations of eligibility, and processes appeals as necessary.
* Must have knowledge of RAI Manual and back-up documentation required and extensive knowledge of state grouper and calculator field relative to RAI and state payment; extensive knowledge of Medicare reimbursement, compliance and eligibility; basic understanding of rehab, dietary, social services and recreational services.
* Conducts routine audits of MDSs and develops work plans with MDS Coordinators to achieve improved performance and optimal outcomes
* Ensures process is in place for the completion of the Resident Assessment instrument per time frames established by CMS and facility policies
* Monitors timely electronic submission of MDS data to the federal database and reviews validation reports
* Ensures resident information is appropriately maintained in computer-based information system.
* Must have knowledge and understanding of QI indicators
* Attends QAPI meetings as necessary to ensure performance standards are met.
* Attends meetings as required and performs other related duties as assigned or requested.
* Carries out supervisory responsibilities in accordance with the organization's policies and applicable laws. 
* Responsibilities include:
*  training employees 
* planning
* assigning, and directing work
* appraising performance; rewarding and disciplining employees
* addressing complaints and resolving problems

* Reports any issues or discrepancies through the chain of command.
* Has ability to work independently with minimal supervision and guidance.
* Has proven written and oral communication skills.
* Has decision making and analytical skills.

Qualifications:

Education:

* Bachelor's degree in a health care or related field, consistent with the duties to be performed required. Master's degree preferred.

Experience:

* Minimum three (3) years of clinical experience in a long-term care setting, which includes supervisory, administrative or consultative capacities, with at least two  (2) years of clinical reimbursement experience.

Knowledge and Skills:

* Ability to work in surroundings with degree of dust, noise, etc. without undue discomfort.
* Ability to hear, talk, walk, stand, bend and stretch
* Ability to read, write and interpret documents
* Ability to communicate effectively with patients and/or co-workers
* Must be trained in and knowledgeable of all Kingsbrook/Rutland and Brookdale/Schulman & Schachne Institute for Nursing and Rehabilitation policies and procedures pertaining to hazardous waste and hazardous materials and maintain qualifications applicable to assigned work

License/Certifications:

* CPM (Certified Purchasing Manager) certification preferred.

Physical Requirements:

* Position requires prolonged periods of standing, reaching, walking throughout the working day.
* Position will be required to stoop, bend, lift, and carry items weighing up to 25 pounds for routine performance of essential functions.
* May be required to handle reasonably heavy weights across distances.
* May be required to handle/ assist in lifting patients onto/out of exam beds/procedure stations.
* Normal routine involves no exposure to blood, body fluid or tissue. Incumbents are not called upon to perform or assist in emergency care or first aid.
			

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The Brookdale Hospital Medical Center