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Villa Maria Nursing Ctr & Rehab Full-Time  North Miami, Florida 33161 United States 22 May 2024

Job Description

Clinical Reimbursement Manager


Summary & Objective

The Clinical Reimbursement Manager oversees and manages the completion of the RAI (Resident Assessment Instrument) by the Interdisciplinary Team (IDT) per federal and state regulatory guidelines. The Clinical Reimbursement Manager completes education for new team members on timeliness, accuracy, MDS section completion definitions, CAA completion and the resident care plan. The Clinical Reimbursement Manager is responsible for completion and submission of timely and accurate MDSs. The Clinical Reimbursement Manager assesses Interdisciplinary Team members competency in understanding and applying the RAI directions when completing portions of the RAI for all residents, and ensures Interdisciplinary team members are educated on service delivery, documentation and accurate capture of services and conditions on the MDS to meet accuracy and MDS definitions resulting in optimized and accurate calculations of case-mix-groups for payers relying on HIPPS for payment. The Clinical Reimbursement Manager evaluates the quality of the data submitted and coordinates with the facility IDT to develop and implement plans for improvement.


Essential Functions

• The Clinical Reimbursement Manager is independently responsible for leading the Interdisciplinary Team to complete the RAI process to meet multiple regulatory requirements per 42 CFR 483.20 (b)(1)(xviii), (g), and (h), and facility policies, when applicable.

• The Clinical Reimbursement Manager ensures the RAI process completion meets the requirements of multiple regulatory programs and agencies, and evaluates the reported outcomes for each program, and develops performance improvement plans when applicable. Programs include the following, but is not an exhaustive list:

• The IMPACT Act mandates that SNFs are to collect and report on standardized resident assessment data (MDS). Failure to report such data results in a 2 percent reduction in the SNFs market basket percentage for the applicable fiscal year per the SNF QRP (Quality Reporting Program).

• Medicare Care Compare public reporting.

• Federal, State and Private Reimbursement requirements

• Quality Measure Reporting (CMS 5-Star, Value Based Purchasing, QRP)

• OBRA regulatory requirements for the RAI completion, encoding, submission success and timeliness.

• AHCA Survey information

• QIOs (Quality Improvement Organizations)

• Research organizations.

• The Clinical Reimbursement Manager completes the nursing sections of the RAI autonomously on behalf of the facility.

• The Clinical Reimbursement Manager makes independent clinical decisions within the scope of their nursing license, regarding care plan development utilizing the data from the MDS, other information gathered from the clinical record, resident interviews, and physical assessments of the resident.

• Coordinates the Interdisciplinary Team to assure completeness of the entire RAI in accordance with federal and state requirements for accuracy and timeliness, and the development of a comprehensive care plan.

• Develops and manages the RAI schedule and establishes ARDs. The RAI schedule indicates when IDT members are to complete MDSs, CAAs, Care Plan Updates and establishment of the Comprehensive Plan of Care. The RAI schedule includes care plan meeting dates and times.

• Ensures the baseline care plan meets minimum criteria and provides a copy of the baseline summary to the resident or responsible party to include at a minimum; initial goals of the resident, list of current medications and dietary instructions, and services and treatments to be administered by the facility and personnel acting on behalf of the facility.

• Ensures that each portion of the RAI is signed and dated by the person who completed that portion of the Resident Assessment Instrument.

· The Clinical Reimbursement Manager conveys the resident care plan to the IDT, suggests changes if/when needed and coordinates the IDT in carrying out the resident care plan.

· Completes all Admission/Discharge Tracking Records for resident chart or medical record file.

· Completes the monthly Triple Check.

· Encodes the facility software and MDS with accurate and up to date diagnosis information (ICD-10), including prioritization of diagnosis for claims and establishment of primary diagnosis.

· Provides quality improvement recommendations and planning based on medical record reviews, analysis of Quality Measure Outcomes and reimbursement trends.

· Participates in facility reviews of medical records and claims prior to submission, when requested by external agencies or upon internal quality improvement initiatives.

· Coordinates weekly review of PDPM residents, to include HIPPS codes, daily skill status, continuing daily skills, anticipated length of stay, appointments scheduled, transportation arrangements and services/treatments or procedures that fall under Consolidated Billing and advises most clinically effective, cost-efficient means of delivery of care and services.

· Ensures and validates all components for technical and clinical coverage requirements for Medicare A are met, to include but not limited to; Qualifying Hospital Stay, Available Medicare days, SNF Certifications and medically necessary daily skilled care is required and being provided.

· Tracks available Medicare A days and skilled level of care for all residents to ensure ALL facility residents are accurately identified when they may be eligible to utilize their Medicare A benefit.

· Complies with Nursing Department policies and procedures.

· Coordinates and conducts the interviewing of each residents/staff/family for the resident’s assessment.

· Maintains accurate and complete reports and submits reports as required to include clinical meetings, QAPI and other meetings as determined by the facility/supervisor.

· Tracks and reports status of the Interdisciplinary Team compliance within the RAI process to supervisors to include timely completion of the RAI components, participation in care planning and attendance at care plan meetings.

· Collaborates with the management team to identify facility needs to facilitate the RAI process.

· Complies with all policies, laws, and regulations at the local, state, and federal level.

· Assists with patient and/or resident care needs as need arises.

· Performs other duties as assigned.


Supervisory Responsibility

May serve as an interim department leader depending on need.


Physical Requirements

Must be able to lift and/or move up to 50 pounds and push/pull up to 250+ pounds, walk, climb stairs or ladders, stand on feet for extended periods of time, etc.



The job description is not designed to cover or contain a comprehensive listing of activities, duties or responsibilities that are required of the employee. Other duties, responsibilities and activities may change or be assigned at any time.


EEOC Statement

CHS provides equal employment opportunities to all employees and applicants for employment and prohibits discrimination and harassment of any type without regard to race, color, religion, age, sex, national origin, disability status, genetics, protected veteran status, sexual orientation, gender identity or expression, or any other characteristic protected by federal, state or local laws.

This policy applies to all terms and conditions of employment, including recruiting, hiring, placement, promotion, termination, layoff, recall, transfer, leaves of absence, compensation, and training.

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