Regional Clinical Reimbursement Specialist - South Central Texas (72143)

About the role

As a Regional Clinical Reimbursement Specialist, you will travel daily to facilities in your Region to promote, plan, organize, develop, coordinate, and direct facility teams in support of Clinical Reimbursement in accordance with State and federal regulatory requirements and company-established policies and procedures. This role ensures the highest degree of quality resident care and safety. You will work under the direction of the Director of Clinical Reimbursement and oversee the administration, clinical planning, development, and operations of the MDS program, supporting regional and facility employees in all aspects of care management.

Responsibilities

• Conduct medical records review utilizing clinical and regulatory knowledge to determine required supporting documentation.
• Perform clinical nursing review of patient records for compliance with facility practices and procedures.
• Flexibly manage tasks to meet deadlines by re-prioritizing workflows in a production-oriented setting.
• Employ critical thinking to identify and resolve issues, providing timely feedback regarding medical review processes.
• Develop appeal arguments using clinical evidence, supporting references, and regulations; participate in appeal hearings by providing testimony as required.
• Determine regulatory and clinical support for appeal arguments when pre-existing resources are unavailable.
• Proficiently review and synthesize abstract information from handwritten or electronic medical records to support claims.
• Agree not to disclose assigned user ID, password, or resident’s protected health information; promptly report suspected or known violations to the Director of Medical Records.
• Report any unauthorized attempt to access the facility’s information system to the Director of Medical Records.
• Attend and participate in mandatory in-service training programs, workshops, and seminars as approved or delegated.

Requirements

• Graduate of an accredited school of nursing, currently registered with a state agency for nursing licensure, and hold a valid license in the state of employment.
• Experience in geriatric/long-term care nursing documentation, Minimum Data Set (MDS) coding, and/or medical necessity reviews/appeals.
• Working knowledge of regulatory and payer requirements for reimbursement and reasons for denial of claims for Medicare, Medicare Advantage, or Medicaid.
• Completion of continuing education on case management, regulatory requirements, restorative nursing, medical records documentation, legal aspects of documentation, reimbursement, and compliance.

Skills

• Analytical: Synthesizes complex or diverse information using experience and judgment to complement data.
• Problem Solving: Identifies and resolves problems in a timely manner; develops solutions; works well in group problem-solving situations.
• Communication: Speaks and writes clearly and informatively; listens and gets clarification; responds well to questions; demonstrates group presentation skills; edits work for spelling and grammar; varies writing style to meet needs.
• Quality: Demonstrates accuracy and thoroughness; excellent attention to detail with a critical eye to catch and correct mistakes and errors; applies feedback to improve performance; monitors own work to ensure quality.
• Character: Demonstrates integrity in every aspect of work and dealing with others; consistently models desired behaviors and values; respects diversity of perspective; demonstrates an inclusive style; shows concern for job safety for self and others.
• Organizational Support: Follows policies and procedures; completes administrative tasks correctly and on time; supports organization’s goals and values.
• Dependability: Follows instructions and responds to management direction; takes responsibility for own actions; keeps commitments and completes tasks on time or notifies the appropriate person with an alternate plan.