MDS Solutions - Clinical Reimbursement Specialist

About the role

The Clinical Reimbursement Specialist (CRS) plays a critical role in supporting clients through specialized project work, including conducting RAI assessments, developing comprehensive care plans, and delivering targeted education and training to MDS Coordinators on the Resident Assessment Instrument (RAI) process. This work is performed in strict alignment with applicable laws, regulations, and company standards. The CRS also reviews reimbursement systems for PDPM and Case Mix to ensure accurate and optimized reimbursement. Additionally, the CRS provides support with interim long-term and short-term contract coordination, ensuring the smooth completion of these efforts.

Responsibilities

• Assist clients in assessing, planning, developing, and implementing systems and processes related to reimbursement, tailored to the specific needs and contracts established with each client.
• Provide consulting services and technical expertise, including interim MDS management, ensuring providers receive the support they need to achieve optimal outcomes.
• Stay up-to-date on professional standards of clinical care, federal and state regulations, QM measures, and the RAI process to ensure the delivery of accurate, compliant, and effective solutions.
• Deliver high-quality, professional services that encompass reimbursement optimization, staff education, in-depth research, system analysis, creative problem-solving, and the presentation of actionable recommendations to clients.
• Identify and address training needs, developing and conducting training sessions or in-service programs as requested by clients to enhance staff competency and performance.
• Operate within the defined scope of work, maintaining strict adherence to client agreements and expectations.
• Uphold client confidentiality and ensure full compliance with HIPAA regulations, safeguarding sensitive information throughout the engagement.

Requirements

• Bachelor’s degree in nursing from an accredited college or university, with at least five (5) years of clinical experience, including 3+ years specializing in the RAI process.
• Current and unrestricted RN, along with active RAC-CT certification, ensuring adherence to industry standards and best practices.
• Possesses exceptional critical thinking skills, with the proven ability to make informed decisions, demonstrate sound clinical judgment, and apply expert knowledge in quality improvement concepts and processes.
• Demonstrates strong leadership abilities and excels in interpersonal communication, fostering collaboration, and guiding teams to achieve optimal clinical outcomes.

Qualifications

• Minimum of five (5) years of clinical experience, including three (3) years specializing in the RAI process.
• Current and unrestricted RN license.
• Active RAC-CT certification.
• Exceptional critical thinking and decision-making skills.
• Proven ability to make informed decisions, demonstrate sound clinical judgment, and apply expert knowledge in quality improvement concepts and processes.
• Strong leadership abilities and excellent interpersonal communication skills.

Skills

• Expert knowledge of the RAI process and PDPM/CapCase Mix reimbursement systems.
• Strong organizational and project management skills.
• Ability to communicate effectively with clients and healthcare agencies.
• Proficiency in data analysis and problem-solving.
• Excellent written and verbal communication skills.

Benefits

• Competitive salaries with bonus opportunities.
• Affordable health, dental, and life insurance packages.
• 401K with discretionary matching.
• Mileage and licensure reimbursements.
• Flexible Spending Account (FSA) and Health Savings Account (HSA) options.

Pay

Competitive salaries with bonus opportunities.

Schedule

Reasonable working hours promoting work-life balance.