Director of Clinical Reimbursement

Position Summary:

 

The Director of Clinical Reimbursement assures the management of the Medicare, Managed Care and MMQ reimbursement for fifteen skilled nursing facilities in Massachusetts. This position reports directly to the Corporate Director of Reimbursement for Care One. You will be responsible for regulatory compliance and quality improvement efforts, in order to attain the appropriate Medicaid/Medicare reimbursement possible for assigned facilities.  Ensure that the services offered exceed federal, state, and company standards. Serve as a role model for ethical business practices according to standards.

 

As the Director of Clinical Reimbursement you will have three direct reports that cover 4 centers and oversee both the Medicare and Medicaid reimbursement for our facilities. They are called Clinical Reimbursement Specialists. The Director themselves will directly cover 3 facilities.

 

 

ESSENTIAL DUTIES AND RESPONSIBLILITEIS include but are not limited to the following:

 Implement and direct Medicare and MMQ auditing and systems reviewAdmission pre-screening Admission documentation requirementsFinancial documentation requirementsClinical DocumentationStrategic selection of assessment reference datesMDS accuracyADL score trackingDenials Management RUGs management Therapy implementation and documentation

 Provide interdisciplinary team trainingMDS and PPS trainingDocumentation requirementsRUGs groups Admission strategiesRole and responsibility of the Clinical Reimbursement CoordinatorManaged Care contracts and updatesHIPPS codingConsolidated Billing Keep facilities informed of trends, developments, concepts and techniques in the MMQ field that affect reimbursement services.Engage facility management team in problem solving process to identify improvement opportunities and achieve solution.Facilitate effective well-organized MMQ meetings, establish productive objectives and follow through with action plans.Work with staff that coordinates the case mix submission process to ensure maximum legitimate reimbursement provided for services delivered to residents in each facility.Evaluate performance of MMQ staff and make recommendations regarding staff assignments, assessment procedure and maximizing reimbursement.  On going evaluation of the effectiveness of reimbursement staff.Fee schedulesIndustry updates and regulation changes

 

3. Financial AnalysisRate projectionsVendor contract strategiesMonthly RUGs distributionLength of stay analysisAssist in Part B program developmentAssist in budget process

 

4.  Clinical AnalysisMonitor weekly utilization review meeting Monitor daily PPS meeting Month end Triple Check Nursing documentation

 

 

RECOMMENDED QUALIFICATIONS:

 Bachelors or Masters Degree in healthcare-related field. Advanced degree in nursing, rehabilitation or healthcare administration.Minimum of 5 years in healthcare.Proven knowledge of quality improvement processes with and emphasis on claim coding, MDS and associated clinical documentation auditing and correction process.Excellent oral and written communication skills. Work processing and related computer skills.Current licensing and credentials as required.