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Clinical Reimbursement Supervisor

Location:St. Louis Park, MN
Employment Type:Full Time
Department:Sholom Home West
Description:Sholom, one of the premier healthcare and senior services organizations in the Twin Cities, has a full-time opening for a knowledgeable, skilled Clinical Reimbursement Supervisor at its beautiful 17 acre campus in St. Louis Park.

The Clinical Reimbursement Supervisor will (a) manage the overall process, staff supervision and tracking of all Medicare/Medicaid case-mix documents in order to assure appropriate reimbursement for services provided within Sholom; (b) conducts concurrent MDS (Minimum Data Set) reviews to assure achievement of maximum allowable RUG (Resource Utilization Group) categories; and (c) integrates information from Nursing, Nutrition Services, Social Services and Rehabilitation to ensure appropriate reimbursement.

Duties:Perform revenue optimization and resource utilization practices and analysis.
  • Track Medicare and HMO residents to determine continued and appropriate eligibility and benefit period by determining skilled level of need.
  • Prior to admission, review pre-admission intake information with the Admissions Nurse to estimate RUG levels for Medicare residents and to identify potential resource costs, consider formularies, and communicate findings to Administrator/care team as needed.
  • Perform concurrent MDS review to insure appropriate RUGs category is achieved through the capture of appropriate clinical information. Identify opportunities to enhance reimbursement.
  • Direct the interdisciplinary team process to communicate opportunities to ensure capturing of all resources.
  • Attend monthly meeting with Business Office and Rehabilitation, to review all PPS (prospective payment system) residents for billing, certification, diagnosis, MDS, and other factors (Triple check).
  • Manage routing for log for skilled and managed care for transitional care unit and ensures that MDSs are done accurate.
  • The supervisor will perform diagnosis sequencing for skilled and managed care for transitional care unit
  • Ensures that certifications are done and signed timely per guidelines
  • Supervises and ensures that MDSs and CAAs are done on a timely basis and coordinates with the MDS staff to facilitate needs/resources.
  • Investigates issues that pertain to inaccurate MDSs, performs root cause analysis, provides feedback and education to MDS coordinator(s) as needed and consults with DON and HR for any corrective action.
  • Ensures that the Medicare A and Medicare B denials are issued and scanned in the residents EMR.
  • Will take part in collaborative Medicare meetings with therapy to coordinate/manage rehab minutes. Will communicate any changes to ARD, Assessments to the MDS staff and ensure that the MDSs reflect the changes
  • Will schedule the LTC and the post acute care unit MDS (Annual, Quarterly, significant changes for LTC) and ensure that MDS coordinators perform MDSs as assigned.
Maintain and monitor MDS schedule and tracking.
  • Maintain all MDS assessments to include the proper reference dates throughout the resident's stay and ensure the accurate and timely submission of the MDS assessments including case-mix, OBRA (Omnibus Budget and Reconciliation Act) and PPS schedules.
  • Communicates to IDT the MDS assessment schedule to ensure timely facilitation of the MDS and care planning process.
  • Completes the admission and discharge racking form and maintains tracking system for admission/re-entry/discharge.
  • Manage the data entry function to ensure the accuracy of the MDS and verify electronic RAI team transmissions to Point Right QI checks prior to state submission.
Coordinate billing process.
  • Coordinate with the Business Office to communicate and verify accurate billing; including contract exclusions.
  • Maintain the Managed Care contract manual to ensure timely communication with appropriate departments and staff.
Provide Medicare and Managed Care reimbursement education to Sholom staff.
  • Serve as the resource for MDS/RUGs, Managed Care and state case-mix systems to staff and families as needed (register for list serve for MDH/CMS).
  • Provide case-mix education to the interdisciplinary team as appropriate.
  • Instruct Sholom staff in terminology, language, and format that is required by MDS.
  • Communicate with Director of Nursing, interdisciplinary team and Business Office regarding any changes in case-mix regulations such as PPS (prospective payment system) and/or state specific case-mix systems.
  • Train back-up staff for the Clinical Reimbursement Supervisor.
Perform administrative and documentation duties as required.
  • Assist in the preparation of all requests from appropriate state and/or federal regulatory agencies or agents regarding payment of services (reconsideration, denials appeals, etc.).
  • Maintain all MDS, case-mix and Point Right reports and transmission data in an electronic format and store in electronic storage files.
  • Able to adhere to the Residents Bill of Rights, HIPAA, and the Nurse Practice Act.
  • Able to keep current on changes in the industry, including clinical and regulatory changes.
  • Able to comply with established Infection Control and Safety Guidelines.
  • Initiative and judgment in determining the needs of residents and maintaining patient care delivery in conformance with recognized standards.
  • Good human relations skills and the ability to monitor and direct the activities of others. Patience, tact, courtesy, and kindness when dealing with the residents, family, physicians, and other staff.
  • Able to enlist cooperation of unit personnel and staff in other departments.
  • Understand the importance of supporting the organization, residents/families/customers and other Sholom employees.
  • Able to display high levels of customer service, responding promptly and thoroughly to the inquiries and needs of individuals both internal and external to the organization in accordance with our PROUD standards.
  • Excellent interpersonal skills to interact effectively with a variety of people and personalities inside and outside the organization. Able to effectively handle interactions at all levels and to respond appropriately in sensitive situations.
  • Communicate clearly and effectively both orally and in writing to all levels of people inside and outside the organization, including possessing good English speaking skills, fluency and understandability.
  • Strong computer skills including Microsoft applications such as Word, Excel, and Outlook, and other applicable clinical packages.
  • Detail-oriented, organized and applies effective time management skills in order to meet all deadlines. Able to work under pressure and work independently.
  • Able to verbalize understanding of written documentation, instructions, general policies and procedures.
Education, Experience and Credentials
  • Must have current licensure as an RN in the State of Minnesota and must maintain licensure.
  • 3-5 years of long term care clinical nursing experience is required. Any leadership role in nursing preferred.
  • Experience with Medicare/Medicaid reimbursement, MDS completion, clinical resource utilization and/or case management with a maximum of 5-7 years, a must.
If you’re interested in working for an organization committed to providing high quality care and services to elderly adults, come join the Sholom team!

Submit applications online at\employment.

3620 Phillips Parkway St Louis Park, MN 55426


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