RN MDS Manager

Clinical Reimbursement Manager

Oversees clinical reimbursement operations and ensures the collection of information (initial and ongoing) for the Minimum Data Set (MDS).

• Ensures the MDS coordinator team works with the nursing department for a comprehensive nursing assessment of the resident/patient health status.
• Demonstrates expertise in the completion of the MDS to capture services provided and facilitate optimal reimbursement.
• Meets with resident/patient in-person to collect information (initial and ongoing) for the Resident Assessment Instrument (RAI) and provides a comprehensive nursing assessment of the resident/patient health status that will be used in addressing anticipated changes in resident/patient condition.
• Completes comprehensive resident assessment (initial, quarterly, annual); ensures that documentation meets requirements of Keswick and regulatory agencies and is sufficient to substantiate reimbursement for Keswick services.
• Completes MDS and MMDS according to established policies and procedures; locks and transmits to the State.
• Performs assessments, including quarterly Braden Scale, quarterly falls, quarterly and annual side rail, and quarterly pain assessment.
• Works to identify coding that reflects the full patient condition and captures all appropriate ancillary and rehab conditions.
• Affirms that documentation meets the requirements of Keswick and regulatory agencies and is sufficient to support MDS coding as well as to substantiate reimbursement for Keswick services.
• Facilitates/assures process for managed care authorizations post admission, reviews contracts for compliance, and seeks carve-outs and appropriate levels of authorized care.
• Oversees or directly participates in the triple check process with administration, rehab, and business office staff to ensure accuracy and regulatory requirements are met prior to billing.
• Mets with rehabilitation director and personnel regularly to ensure documentation compliance and accuracy.
• Facilitates Utilization Review meetings or assigns designee.
• Identifies recurring problems and communicates to appropriate staff for resolution.
• Provides support for state and/or federal surveys, as needed.
• Oversees the tracking system of MDS schedules (timeframes and due dates).
• Seeks knowledge/clarification related to reimbursement regulation and MDS completion.
• Takes initiative to analyze the CASPER for potential areas of opportunity to improve clinical outcome measures for the Five-Star Report and other clinical indicators.
• Works with the interdisciplinary team to develop action plans for improved capture of MDS documentation.
• Works to implement strategies to optimize Keswick’s CMI as a reflection of documented services provided.
• Prepares quality assurance reports and interprets/analyzes data for quality assurance purposes.
• Ensures timeliness of compliance with external audits, i.e., Telligen, pre/post payment reviews.
• Ensures timely completions of 3871s, Continued Stay Reviews, etc.

Qualifications

• Registered Nurse (RN), licensed and in good standing with the Maryland Board of Nursing, required.
• Resident Assessment Coordinator Certified (RAC-CT) certification is desirable.

Knowledge

• Resident Assessment Instrument (RAI) manual, nursing and rehabilitation practice and principles;
• Applicable laws and regulations governing long-term care and/or sub-acute (short stay) care;
• Reimbursement requirements;
• Diseases, conditions and treatment therapies for the patient population;
• MDS coding and regulations;
• ICD-10 Coding;
• Radiation coding;
• Patients’ rights and the nursing role in helping protect and enhance those rights;
• Principles and requirements for documentation and medical record management;
• Computerized healthcare systems and medical records systems.

Skills

• Using MDS computer program;
• PointClickCare (PCC) and Microsoft Office software and other software;
• Communicating with other care providers and administrative officials;
• Effective listening and critical observations and utilizing the information for effective problem solving;
• Relating to and working with the elderly, ill, disabled, recovering, emotionally upset, and at times hostile people with tact and sensitivity.