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SUMMARY: The Regional Reimbursement Consultant is responsible for the accurate and timely completion of all Medicare/Medicaid case-mix documents in order to assure appropriate reimbursement for care and services provided within the Facility. Conducts continual Minimum Data Set (MDS) reviews to assure achievement of optimal allowable Resource Utilization Group (RUG) category. Oversees the overall process and tracking of MDS/Prospective Payment System (PPS) documentation and submission. He/she will integrate nursing, dietary, social recreation, restorative, rehabilitation and physician services to ensure appropriate assessment and reimbursement.

ESSENTIAL DUTIES AND RESPONSIBILITIES:

+ Ensures that the facility is in compliance with the organization’s policy and procedures and complies with all state regulations

+ Understands and implements company policies and procedures

+ Ensures the accurate and timely completion of all MDS Assessments including PPS Medicare, quarterly, annual, significant change.

+ Participates in care conferences as need or requested by facility

+ Performs comprehensive assessment on potential residents

+ Provides clinical training and support to all staff

+ Verifies electronic submissions of MDS, performs corrections when necessary and maintains appropriate records.

+ Coordinates interdisciplinary participation in completing the MDS for each resident according to regulatory time frames. Ensures completeness and thoroughness of documentation as mandated by federal and state standards.

+ Schedules and conducts resident care conferences in compliance with state and federal regulations and ensures completion of all MDS reviews prior to resident care conference.

+ Assists disciplines in formulating and revising care plans. Ensures that resident’s present/potential problems are identified and prioritized; realistic goals are established and nursing intervention is appropriate.

+ Evaluates resident care plans for comprehensiveness and individuality.

+ Assesses the achievement or lack of achievement of desired outcomes. Ensures that resident’s care plan is reassessed and revised appropriately.

+ Responsible for all level of care changes within the facility. Notifies all departments when a level of care change has been made.

+ Generates appropriate forms to complete level of acuity and changes. Transmits forms to the appropriate agency for processing as required by state law.

+ Addresses complaints and resolves problems as needed.

QUALIFICATIONS: To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements below are representative of the knowledge, skill, and/or ability required.

+ Bachelor’s Degree in Nursing required.

+ Five years management experience with experience in long-term care

+ Must possess a current, unencumbered, active license to practice as an RN in the state.

+ General knowledge of professional basic nursing, restoratives and personal care services

+ Ability to read and interpret documents, write reports, and correspondence.

+ Must have a valid driver’s license

+ High level of interpersonal skills to handle sensitive and confidential situations and documentation, and interaction with coworkers.

PHYSICAL DEMANDS: The physical demands are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

+ Must be able to move intermittently throughout the workday.

+ Must be able to push, pull move and/or lift a minimum of 50 pounds to a minimum height of 5 feet and be able to push, pull, move and/or carry such weight a minimum distance of 50 feet.

+ The noise level in the work environment is usually moderate.

+ Ability to travel within the assigned region, up to 75%

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