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

• Support clients through specialized project work, including conducting RAI assessments, developing comprehensive care plans, and delivering targeted education and training to MDS Coordinators on the RAI process.
• Review reimbursement systems for PDPM and Case Mix to ensure accurate and optimized reimbursement.
• 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.
• A current and unrestricted RN license, along with active RAC-CT certification, ensuring adherence to industry standards and best practices.
• 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 3+ years specializing in the RAI process.
• Current and unrestricted RN license, along with active RAC-CT certification.
• 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.
• Strong leadership abilities and excellent interpersonal communication skills.

Skills

• Expert knowledge of the RAI process and PDPM/CapCase Mix reimbursement systems.
• Ability to conduct RAI assessments and develop comprehensive care plans.
• Strong organizational and time management skills.
• Excellent interpersonal and communication skills.
• Proficiency in Microsoft Office Suite and other relevant software tools.

Benefits

Competitive salaries with bonus opportunities
Ample opportunities for promotion, transfer, and advancement
Reasonable working hours promoting work-life balance
Continuing education (CE) opportunities for ongoing professional development
Generous paid time off
Comprehensive 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