Overview

Provides extensive training, analysis, advice, and consultation to the facilities and regional teams within his/her area of responsibility. Ensures compliance with federal and state regulations, as well as company policy and procedures regarding state Case Mix/Medicare and Managed Care payment systems. Monitors, consults, and make effective recommendations for changes and modifications to existing facility processes, systems, policies, and practices which will assure efficient, effective and compliant state Medicaid/Medicare/Managed Care payment performance. Manages the activities and performance of the Care Management Specialist in the facilities. Follows all RIHS policies and procedures.

Essential Job Duties and Responsibilities

Provides consultation, training, and support concerning the Medicare, Managed Care and state Case Mix payment systems for the assigned area. Analyzes systems and processes to determine that federal and state regulations as well as company policies and procedures are followed. Promotes compliance by performing periodic audits of MDS assessments, supporting documentation, and other relevant data. Participates, when necessary, in the pre-admission process to ensure essential information needed for MDS/Case Mix optimization and medical necessity determination is obtained from the referral source(s). Recognizes, advises, and promotes facility best practices and systems for dealing with state Case Mix/Medicare, and Managed Care payment systems. Studies, analyzes, and reports period over period information and systems to identify trends and deviations from expected results in Medicare RUG scores, Managed Care and state Case Mix Index and takes appropriate actions. Works in conjunction with regional teams to resolve issues effecting deviations from expected results. Recommends changes and performs follow-up to ensure that those recommendations are effectively implemented and monitored for appropriateness. Regularly communicates to management outside the facility on recommendations made to facility management to ensure proper implementation and follow-up. Serves as a liaison between state and organization related to the state Case Mix process, including electronic submission and state MDS requirements related to state payment. Attends state sponsored Case Mix training as indicated. Attends regional meetings, as well as company conference calls and training as appropriate. Works with regional team to coordinate training to facility team members on state Case Mix/Medicare/Managed Care payment systems. Completes Facility Site Visits and Quality Review audits as directed, evaluating Case Mix, RAI/Medicare process and compliance, rate optimization, Medicare LOS, ADL, and Skilled note documentation, Care Management Meetings, and Quality Measures and communicates findings to facility leadership and regional team. Identifies facility and regional education needs and provides small/large group and individual training as needed. Assists in the recruitment/interview process for Care Management vacancies. Participates in daily Case Management, weekly Level of Care meeting, monthly Triple Check and other meetings per RIHS policy. Assists in the preparation and timely submission of any Additional Development Requests (ADRs), Reconsideration and Administrative Law Judge (ALJ). Functions as an RAI and Clinical Reimbursement resource to the facility staff and regional team.

Other Duties

Maintains current knowledge of reimbursement regulations. Maintains data in an organized, easily retrievable manner. Maintains good personal hygiene and follows dress code requirements. Communicates regularly with the Director of Care Management to discuss identified clinical reimbursement issues. Other duties as assigned or needed.