Director, Regional Clinical Reimbursement

Skilled Nursing, Residential Health Care & Post- Acute facilitiesHome Health Therapy and RehabilitationWe consistently outperform our peers in every CMS 5-Star Quality Measure, out-score our peers in every CMS 5-Star rating, and consistently achieve a 30-Day Readmissions rate lower than our peers. We are Family Serving Families As part of the Resource Center team, the primary purpose of this position is to partner with facilities as the primary resource to manage and ensure excellence in the execution of the RAI process. Delegation of AuthorityAs the Regional Clinical Reimbursement, you are delegated the authority, responsibility, and accountability necessary for carrying out your assigned duties. Job FunctionsEvery effort has been made to identify the essential functions of this position. However, it in no way states or implies that these are the only duties you will be required to perform. The omission of specific statements of duties does not exclude them from the position if the work is similar, related, or is an essential function of the position.Duties and Responsibilities:

• Conducts facility reviews, to assess compliance with Federal and State regulations related to the MDS/RAI process and associated Covenant Care internal standards. Prepares reports as identified.
• Quality assurance of MDS/RAI process within assigned facilities.
  • Attend triple check quarterly for each facility assigned.Attend Care management meetings at lease quarterly more often if needed.Review QMs monthly.Review QASP monthly.Perform nutritional audits monthly follow up as needed.Review care plan dashboard monthly follow up as needed.Review MDS schedule monthly follow up as needed.Run and follow up on the missing assessment report in Simple monthly.Review care management tracker monthly.Review in Simple the QRP QMs monthly.Review Medicare certs to ensure completed and done timely.Review for MD orders being signed for billing.Review for extensive care nursing grouper monthly for appropriate coding.
  • Conducts audits for MDS Coding accuracy monthly.
  • Evaluate MDS/RAI practices for consistency with Standards of Professional Practice, State Nurse Practice Act and compliance with company standards and regulatory requirements.
  • Facilitates root cause analysis process and development of action plans for improvement of state quality measure programs (i.e. CA QASP, NV CMI, etc.).
  • Assist in developing and implementing facility specific quality improvement charters and action plans.
  • Provide recommendations to facility staff to maintain compliance with legal, ethical and professional requirements.
    • Follow-up on trends assisting with development of specific action plans to meet practice standards and/or strategic plan initiatives.
    • Keeps current on State and Federal regulations, assisting with interpretation as needed and identifying the impact of service delivery and documentation impact Medicare and Medicaid reimbursement programs. Mentor IDT members in position accountabilities and execution of the Care Management processes.
    • Provide relevant educational information so facility teams are able to make solid alternative decisions when managing the MDS Process.
    • Assist in the interviewing and orientation of new MDS Coordinators.
    • Supports facilities, as needed, during MDS position vacancies.
    • Participates in the mock survey process.
    • Provide recommendations during preparation and throughout the survey process.
    • Participate as a key member of the Regional MDS Team; communicates identified challenges and recommended solutions.
    • COVID audits as needed.
    • Use of appropriate interpersonal skills in all contacts with residents, patients, family members and visitors, other healthcare personnel, supervisors and staff.
    • Treats everyone and especially our residents and patients, with kindness, respect, dignity and genuine caring.
    • Interacts with everyone in a friendly, courteous manner that recognizes everyone as a unique, special human being.
    • Utilizes a positive, 'can do' approach in all interactions with patients, residents, family members, fellow employees, caregivers, Case Managers, etc.
    • Takes the initiative whenever they can to identify clinical or service problems, identify solutions, and works with our fellow employees and managers to implement them.
    • Provide high quality service to everyone, as though they are your family.Minimum Requirements:Education
      • Graduate of an accredited School of Nursing.
      • BSN Preferred.
      • Current licensure in State(s) where practicing.Specific Experience
        • Must be able to travel by plane and car to assigned work locations. Travel requirements are heavy at 50%-75% of the normal work week.
        • Must be able to read, write, speak, and understand the English language.
        • Requires the ability to make independent decisions when circumstances warrant such action.
        • Requires the ability to deal tactfully with personnel, residents, family members, visitors, government agencies/personnel, and the general public.
        • Must be knowledgeable of RAI Guidelines, Medicare Reimbursement Rules, as well as state Medicaid laws, regulations, and guidelines that pertain to Skilled Nursing Facilities.
        • Must be knowledgeable of nursing and medical practices and procedures, as well as laws, regulations, and guidelines that pertain to long-term care.
        • Requires leadership and supervisory ability and the willingness to work harmoniously with and supervise other personnel.
        • Requires the ability to plan, organize, develop, implement, and interpret the programs, goals, objectives, policies and procedures, etc., that are necessary for providing quality care.
        • Must have patience, tact, a cheerful disposition and enthusiasm, as well as the willingness to handle difficult residents.
        • Must be willing to seek out new methods and principles and be willing to incorporate them into existing nursing practices.
        • Must not pose a direct threat to the health or safety of other individuals in the workplace.Preferred Requirements:Experience
          • Membership in professional organization(s) desirable.
          • Preferred five years experience in Long Term Care.
          • Preferred at least five years experience in MDS or RAC Credential with less experience

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