Reimbursement Services Director jobs in Dayton, OH

We offer a comprehensive Benefit package to Full Time Employees:

• PTO
• 401-k with Company match
• Health Insurances
• Company Paid Life Insurance
• Tuition Reimbursement
• Employee Assistant Program

Job Summary.

Responsible to review Medicare/Medicaid documentation to assist nursing centers in completing MDS 3.0 documentation to assure appropriate levels of Medicare and/or Medicaid reimbursement.

The Director of Clinical Reimbursement will oversee the clinical reimbursement and case management services within the organization and will report directly to the Vice President of Clinical Services. These services include Medicare A and B, managed care, insurance, and Medicaid Essential Qualifications::

 • Multi facility/regional Supervisor experience • 5 years MDS experience • Active RN license required with RAC-CT preferred

 • 2 years previous management experience Essential Functions::

 • Directly manages the MDS Team in multiple sites.

 • Ensure compliance with clinically-based reimbursement procedures.

 • Ensure compliance throughout the organization with the guidelines for the Minimum Data Set (MDS), Quality Measures, Medicaid and Medicare RUGs, Medicaid Case Mix, and Medicare’s skilled level of care criteria including the supportive documentation requirements.

 • Performs periodic review of MDS 3.0 documentation for accuracy and appropriateness.

 • Performs periodic resident medical chart audits to monitor that services captured on the MDS matches resident needs and documentation reflects categories for case mix reimbursement. Process MDS(s) when necessary.

 • Monitors LTCQ reports for accuracy of MDS coding.

 • Monitors and assists with validation of Quality Measure reports for accuracy of MDS coding.

 • Monitors that facilities follow current RAI Manual and CMS regulatory guidelines.

 • Updates MDS teams on RAI and CMS regulatory changes; revises policy and procedures as needed.

 • Assists licensed nursing staff in improving MDS assessment skills through formal and informal training. Coordinates training and communication with Clinical Services staff as needed.

 • Performs audits per company and divisional standards and policies. Reviews required documentation tools; to ensure appropriate levels of reimbursement.

 • Attends and participates as needed meetings, PPS Meetings, Triple Check Meetings, scheduled in-service programs, staff meetings.

 • Maintains confidentiality of necessary information.

 • Collaborates with all sites and/or site staff related to denial issues affected by the MDS.

 • Works with finance, MDS, nursing and medical records staff to assure appropriate levels of reimbursement.

 • Monitors facility schedules to assure the complete and timely submission of MDS data according to Federal and State reimbursement requirements.

 • Collaborates with the facility to keep them informed of new developments for Federal and State payment systems.

 • Communicates and coordinates the resolution of facility issues related to the MDS process through appropriate departments. 

• Collaborates in the development of new processes, forms, and systems, including the adoption of technology.

 • Ensures MDS team members coordinate with other members of the Inter-Disciplinary Team (IDT) the development and implementation of a plan of care that meets the individual needs of each resident.

 • Maintains a monitoring system by which new admissions, annual reviews, and quarterly reviews are initiated and completed within the required periods. 

• Participates in training of PCC and POC coding for nursing staff as needed.

• Tracks, trends, and analyzes QM for all SNFs to identify vulnerabilities and plan of action.

Responsibilities:

1. Reviews MDS 3.0 documentation for accuracy and appropriateness; Audits resident’s chart to monitor that services match resident needs and documentation reflects categories for case mix reimbursement.
2. Monitors LTCQ reports for accuracy of MDS coding.
3. Monitors and assists with validation of Quality Indicator reports for accuracy of MDS coding.
4. Assists Director, Case Mix Reimbursement with developing training materials for quarterly MDS training sessions. Presents information at quarterly MDS training sessions.
5. Monitors that facilities follow Medicare/Medicaid regulatory and Capital Health Care Network reimbursement guidelines.
6. Assists nursing staff in improving MDS assessment skills through formal and informal training. Coordinates training and communication with Clinical Services staff as needed.
7. Performs audits per company and divisional standards and policies. Reviews required documentation tools; for example,  Billing Logs, to ensure appropriate levels of reimbursement.
8. Monitors Corporate Compliance policies and notifies appropriate facility, regional, divisional, and corporate staff as needed.
9. Attends and participates as needed in regional meetings, PDGM Meetings, scheduled in-service programs, staff meetings and other center meetings and sits on required committees.
10. Participates in developing and updating Medicare PDPM and Case Mix policies and procedures.
11. Completes and maintains records and reports as required for monthly operations meeting.
12. Coordinates and promotes work between departments; Maintains confidentiality of necessary information.
13. Collaborates with corporate and/or facility staff related to denial issues affected by the MDS.
14. Works with facility, corporate and regional support staff to assure appropriate levels of reimbursement.
15. Monitors submission requirements according to Federal and State standards.
16. Monitors to assure the complete and timely submission of MDS data according to Federal and State reimbursement requirements.
17. Collaborates with the facility to keep them informed of new developments for Federal and State payment systems.
18. Remains abreast of regulatory change for Medicare/Medicaid reimbursement and communicates necessary information to appropriate personnel.
19. Communicates and coordinates the resolution of facility issues through appropriate regional and corporate departments.
20. Performs any miscellaneous work assignments as may be required.

Educational/Job Requirements

1. Education: Registered Nurse required.
2. Experience: Three years previous MDS experience preferred; Strong management and interpersonal skills; Case Mix experience required; Computer literate and proficient with applications in the clinical area. Point Click Care experience preferred.
3. Physical Demands: Work is primarily sedentary in nature, with exerting up to 10 pounds of force occasionally and/or a negligible amount of force frequently to lift, carry, push, pull or otherwise move objects, including the human body. Involves sitting, talking, hearing, and seeing; also requires travel by car and airplane.
4. Travel: 90%.
5. Working Conditions: Primarily inside in well-lighted, well ventilated areas.
6. Principal Contacts: VP, Administrator, DON, ADON of Clinical Documentation, MDS Coordinator, Business Office Manager, Director of Rehabilitation and other facility staff, regional and divisional staff, corporate reimbursement staff, and Medicare and Medicaid representatives.
7. General Requirements: Must be able to execute all terms and conditions set forth in the Capital Health Care Network Employee Handbook, including, but not limited to:
   • Works in a safety-conscious manner which ensures that safe work practices are used in order not to pose a risk to self or others in the workplace.
   • Complies with company policies and procedures and local, state, and federal regulations.
   • Adheres to policy on Drug Free Workplace.
   • Interacts in a tactful, diplomatic, and humanistic manner with residents, families, visitors, and co-workers to provide a safe, efficient, and therapeutically effective caring environment which ensures the self-respect, personal dignity, rights and physical safety of each resident and center guest.
   • Maintains a dependable attendance record and adheres to standards of cleanliness, grooming, hygiene, and dress code.
   • Takes positive action to ensure equal opportunity in the conduct of all business activities without regard to race, color, religion, sex/gender, age, national origin, disability, citizenship, veteran status or any other legally protected category.
   • Have fun in making a difference in resident’s and staff daily. p. At Capital Health Care Network, our company culture is built on the following seven essential skills of teamwork:

Active Listening: Team members listen to each other’s ideas. They are observed validating ideas through active listening and “piggy-backing” (or building) off each other’s ideas.
Communication: Team members communicate. They are observed interacting, discussing, and posing questions in an effort to fortify understanding and dispel miscommunication.
Persuading: Team members use persuasion. They are observed exchanging, defending, and rethinking ideas with the greater good in mind.
Respecting: Team members respect the opinions of others. They are observed encouraging and supporting others’ ideas and efforts.
Helping: Team members help. They are observed offering assistance to each other.
Sharing: Team members share. They are observed sharing ideas, information and influence.
Participating: Team members participate. They are observed participating in social media, campaigns, and projects.