REGIONAL CLINICAL REIMBURSEMENT SPECIALIST

Job Details: Job Location: INNOVATIVE NURSE CONSULTING LLC - DALLAS, TX, Salary Range: Undisclosed, Job Shift: Any, Regional Clinical Reimbursement Specialist 

As a Regional Clinical Reimbursement Specialist, you will travel daily to facilities in your Region to promote, plan, organize, develop, coordinate, and direct our facility teams in support of Clinical Reimbursement in accordance with State and federal regulatory requirements and our company’s established policies and procedures to assure that the highest degree of quality resident care and safety be maintained.  

You will work under the direction of the Director of Clinical Reimbursement and be responsible for the executive oversight of the administration, clinical planning, development, and operations of the MDS program. This position supports regional and facility employees in all aspects of care management. 

ESSENTIAL DUTIES AND RESPONSIBILITIES: 

Medical records review utilizing clinical and regulatory knowledge to determine required supporting documentation 

Clinical nursing review of patient records for compliance with facility practices and procedures as directed  

Flexibly manage tasks to meet deadlines by re-prioritizing workflows in a production-oriented setting 

Employ critical thinking to identify/resolve issues and provide timely feedback regarding medical review processes 

Develop appeal arguments using clinical evidence, supporting references/regulations, and 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/electronic medical records to support claims 

Agree not to disclose assigned user ID code and password for accessing resident/facility information and promptly report suspected or known violations of such disclosure to the Director of Medical Records. 

Agree not to disclose resident’s protected health information and promptly report suspected or known violations of such disclosure to the Director of Medical Records. 

Report any known or suspected unauthorized attempt to access facility’s information system to Director of Medical Records. 

Attend and participate in mandatory in-service training programs, workshops, seminars, etc., as approved / delegated.  

Qualifications: EDUCATION: 

 Must be a graduate of an accredited school of nursing, currently registered with a state agency for nursing licensure, and hold a valid license in the state he/she is employed.  

 QUALIFICATIONS/EXPERIENCE: 

 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 reason(s) for denial of claims for Medicare, Medicare Advantage, or Medicaid. 

 Completion of continuing education on subjects related to case management, regulatory requirements, restorative nursing, medical records documentation, legal aspects of documentation, reimbursement, and compliance.  

 SKILLS/COMPETENCIES 

Analytical - Synthesizes complex or diverse information using experience and judgement to complement data 

Problem Solving – Identifies/resolves problems in a timely manner; develops solutions; works well in group problem solving situations 

Communication – Speaks/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/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 established by the company; respects diversity of perspective in discussions and demonstrates an inclusive style; demonstrates concerns 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 appropriate person with an alternate plan