GENERAL PURPOSES:

Functions as a key member of the team and coordinates with the Ancillary and Reimbursement Services team to develop training of Medicare/PPS and Medicaid Reimbursement programs. Consults with division, region and facility staff on Medicare and Medicaid procedures to ensure appropriate utilization of the reimbursement system.

ESSENTIAL JOB FUNCTIONS:

CONSULTATION FUNCTION: Provides consultation and assistance to facilities on Medicare and Medicaid-related areas including eligibility, certification coverage, documentation, utilization and reimbursement. Assists facilities with initial certification procedures and follow-up of problem areas. Updates region and facility staff of any changes. Responds to requests from Regional Vice President for assistance, including recruiting, interviewing, selection and training of Medicare/PPS Coordinator and/or Medicaid Reimbursement Coordinator.

COORDINATION FUNCTION: Interacts with Administrators, DON's, Medicare/PPS Coordinators and Medicaid Reimbursement Coordinators to assist facilities in complying with company procedures and federal, state and local regulations. Interacts with regional clinical and operational teams to ensure consistent implementation and training on policy and procedures affecting reimbursement. Interacts with the Medicare intermediary and all state agencies in professional areas of coverage and documentation. Works with the various therapies and restorative systems to ensure state and federal requirements are met for reimbursement.

MONITORING FUNCTION: Conducts on-site visits to assess compliance with Medicare and Medicaid guidelines as well as company procedures. Establishes systems and programs designed to correct any non-compliance situations. Assesses the coordination and documentation is satisfied for the Resident Assessment Instrument and the 3652 TILE reimbursement system. Monitors timely submission, by facility personnel of all required assessment information including MDS’s, 352’s, 3618’s, and 3619’s.

ADMINISTRATION FUNCTION: Establishes and maintains current statistical data associated with the Medicare and Medicaid programs by region. Cooperates with operations to monitor activities for contractor programs, i.e., therapies, utilization reviews. Reviews and maintains Medicare and Medicaid reference materials. Assists with identification of accounts receivable problems and coordinates with Financial Consultants to resolve. Develops and maintains a process and format for responding to Medicare post-payment reviews and Medicaid Level-of-care reviews.

REPORTING FUNCTION: Provides entrance interviews, and gives exit reports to facility management with a copy to RVP. Provides lists of all necessary follow-up items that need to be prepared by facility clinical staff, including MDS’s, Purpose Code E’s, R’s, etc., 3652’s to Nurse assessor(s) with a copy to DON and Administrator. Performs an assessment of facility clinical staff’s compliance with timeliness and accuracy of all required submissions and reports recommendations for necessary training to RVP’s. Reports to Regional Vice President and VP for Financial Management the results of facility interactions as required. Maintains all written documentation as required.

MEETING FUNCTION: Coordinates, facilitates and attends group and operations meetings as required. Provides and trains facility staff on the purpose and format of weekly Level of Care meetings.

STAFF DEVELOPMENT FUNCTION: Attends and participates in training and educational activities.

OTHER JOB DUTIES: All other duties as assigned.

PHYSICAL AND SENSORY REQUIREMENTS (WITH OR WITHOUT THE AIDE OF MECHANICAL DEVICES):

Walking, reaching, bending, grasping, pushing, and pulling, ability to communicate with personnel, ability to read and write, ability to understand and follow written and oral instructions and directions, ability to remain calm under stress, and the ability to instruct other staff.

QUALIFICATIONS:

Must be a licensed nurse in good standing and currently licensed in Texas.
Prefer five years experience in long term care with a good working knowledge of Medicare/Case Management/Medicaid.
Must have knowledge of PPS requirements, 3652’s, reimbursement forms and the necessary documentation.
Must have computer skills and proficiency.
Must have excellent communications and teaching skills in both individual and group settings.
Must be capable of maintaining regular attendance and be available for travel to include overnight travel as required.
Must be capable of performing all the essential job functions of this position, with or without reasonable accommodations.

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