Vice President of Clinical Reimbursement Greater Philadelphia, PA Area

Position Summary

The Vice President of Clinical Reimbursement will oversee the activities of the Clinical Reimbursement Specialist(s) to ensure RAI guidelines are followed throughout the Eastern division with a focus on resident care and maximizing financial reimbursement through the MDS process.

General Purpose

To provide guidance and oversight to the Clinical Reimbursement Specialist(s) and assessment coordinators within the Eastern division related to the MDS and subsequent reimbursement processes for accuracy in assessment completion and maximization of reimbursement through both PPS and case mix

Role Qualifications

• Minimum of 7 years as an active Registered Nurse in the Commonwealth of Pennsylvania
• A minimum of 5 years in long term care with MDS experience required
• Extensive knowledge of the RAI process and reimbursement requirements for both PPS and case mix
• BSN required, RAC-CT certification

Job Duties and Responsibilities

• Review of MDS assessments on a minimum of a quarterly basis including; quarterlies, annuals, significant changes and admission assessments to ensure scheduling and completion are in compliance with the RAI process and any related state and/or federal regulations to include CAA’s and the care planning process.
• Quarterly review of admissions/discharges to ensure discharge and/or re-entry assessments are present and dated appropriately.
• Review of Medicare PPS assessments on a minimum of a quarterly basis including dually coded full assessments to ensure accurate coding on all sections of the MDS with supportive documentation present to maximize financial reimbursement.
• Review of Medicare assessment scheduling on a monthly basis to monitor use of grace days.
• Monthly review of Medicare certifications to ensure appropriate documentation is present and signed by licensed professional in accordance with federal and/or state regulations.
• Monthly review of each facility RUG report to review distribution and monitor for any trends.
• Participation in facility pre-survey processes with a focus on the MDS process and associated reimbursement.
• Review of Case Mix Report on a quarterly basis to ensure accuracy.
• Monthly scheduling of MDS Coordinator conference call with Clinical Reimbursement Specialist to review Case Mix projections for each facility in the Eastern division.
• Assist facility in orientation of MDS Coordinator when a vacancy is filled.
• Provide mentoring and guidance to assessment offices as needed during on-site visits as well as via email and telephone.
• Planning and implementation of MDS Coordinator Conference(s).
• Develop and revise policies and procedures and subsequent implementation related to MDS and processes associated with.
• Monitor activities of Clinical Reimbursement Specialist by making periodic visits to all facilities within the Eastern division
• Participation on corporate level committees as assigned by the Chief Operating Officer
• Development of quarterly newsletter for clinical reimbursement
• Experience in developing templates to utilize in facility for audit and/or educational sessions
• Other duties as assigned

Essential Knowledge, Skills and Ability

Education/Certifications/Experience

• EDUCATION: High school diploma or GED is required. Associate’s or Bachelor’s degree in Nursing preferred.
• LICENSURE/CERTIFICATION: Current RN license is required and must be in good standing with the Commonwealth of Pennsylvania. Possession of a current Basic Life Support for Health Care Providers CPR certificate.
• EXPERIENCE: Previous experience in completion of Resident Minimum Data Sets and Care planning preferred. Basic computer knowledge is essential.

Knowledge

• CUSTOMER AND PERSONAL SERVICE: Knowledge of principles and processes for providing excellent customer and personal services.
• ENGLISH LANGUAGE: Must have the ability to read, write, and follow oral and written directions at a level necessary to accomplish
• PSYCHOLOGY: Recognizing and being sensitive to resident and family concerns, stressors during time of admission or financial difficulty.
• SAFETY AND SECURITY: Knowledge of relevant equipment, policies, procedures, and strategies to promote effective local, state, or national security operations for the protection of staff and residents, data, and the Facility as a whole.
• MATHEMATICS: Ability to perform basic mathematics.