Director of Clinical Reimbursement

The Director of Clinical Reimbursement has the primary responsibility for the administrative management of the Clinical Reimbursement Department and clinical recording in MDS and related documents for the skilled nursing facility. This position is responsible for planning, organizing, and directing the overall operation of the department in accordance with current federal, state, and local standards, guidelines, and regulations governing skilled and long-term care.

ESSENTIAL JOB DUTIES

1. Oversees clinical reimbursement operations and ensures the collection of information (initial and ongoing) for the Minimum Data Set (MDS). Ensures the MDS coordinator team works with the nursing department for a comprehensive nursing assessment of the resident/patient health status.
2. Demonstrates expertise in the completion of the MDS to capture services provided and facilitate optimal reimbursement. Ensures the appropriate MDS is completed timely for the various circumstances related to admission and quarterly assessments, interrupted stay, change of condition, etc.
3. Works to identify coding that reflects the full patient condition and captures all appropriate ancillary and rehab conditions.
4. Acts to ensure timeliness of MDS completion.
5. Assures that documentation meets requirements of Keswick and regulatory agencies and is sufficient to support MDS coding as well as to substantiate reimbursement for Keswick services.
6. Oversees or directly participates in the triple check process with administration, rehab, and business office staff to ensure accuracy and regulatory requirements are met.
7. Meets with rehabilitation director and personnel regularly to ensure documentation compliance and accuracy.
8. Leads Utilization Review meetings or assigns designee.
9. Identifies recurring problems and communicates to appropriate staff for resolution.
10. Reviews medical information, as requested, for potential admissions.
11. Provides support to state and/or federal surveys, as needed.
12. Oversees the tracking system of MDS schedules (timeframes and due dates)
13. Seeks knowledge/clarification related to reimbursement regulation and MDS completion.
14. Participates as team member in review of quality reporting and other data in which clinical reimbursement may have positive impact on clinical outcomes.
15. Communicates and consults with other health team members.
16. Prepares quality assurance reports and interprets/analyzes data for quality assurance purposes.
17. Participates as an organizational leader. Supports Keswick’s overall mission, vision, and values.

KNOWLEDGE, SKILLS AND ABILITIES REQUIREMENTS

KNOWLEDGE OF: Resident Assessment Instrument (RAI) manual, nursing and rehabilitation practice and principles; applicable laws and regulations governing long-term care and/or sub-acute (short stay) care; reimbursement requirements; diseases, conditions and treatment therapies for the patient population; MDS coding and regulations; ICD-10 Coding; Rehabilitation coding; patients’ rights and the nursing role in helping protect and enhance those rights; principles and requirements for documentation and medical record management; computerized healthcare systems and medical records systems. Must be able to read, write, and understand the English language.

SKILL IN: Using MDS computer program; Point Click Care (PCC) and Microsoft Office software and other software; communicating with other care providers, and administrative officials; effective listening and critical observations and utilizing the information for effective problem solving; relating to and working with the elderly, ill, disabled, recovering, emotionally upset and at times hostile people with tact and sensitivity.

EDUCATIONAL REQUIREMENTS: Bachelor’s degree in nursing.

WORK ORIENTATION & EXPERIENCE REQUIRED:

Registered nurse, licensed and in good standing with the Maryland Board of Nursing required.

Resident Assessment Coordinator Certified (RAC-CT) certification desirable.

PHYSICAL REQUIREMENTS & ENVIRONMENT/WORKING CONDITIONS:

Work is performed in a healthcare environment and an office environment. Occasionally bends, lifts and carries objects up to 10 pounds intermittently throughout the workday. Constant use of computer keyboard and monitor. Requires ability to talk, hear and smell. Requires close vision, distance vision, depth perception, color vision and ability to adjust focus. May experience stress during emergency situations or due to multiple demands from residents, families, and staff. Some local travel may be necessary. Exposure to communicable diseases, toxic substances, and conditions common to a health care clinical environment requiring the use of personal protective equipment and adherence to standard precautions policy.

Keswick is an Equal Opportunity Employer.

This is an exempt position, Core hours: 8:30 am – 5 pm