Registered Nurse Clinical Reimbursement Specialist

Title: Registered Nurse (RN) Clinical Reimbursement Specialist | Long-term care

Full time

Location:

Avera at Home Sioux Falls

Worker Type:

Regular

Work Shift:

Day Shift (United States of America)

Pay Range:

The pay range for this position is listed below. Actual pay rate dependent upon experience.

$78,000.00 - $116,480.00

Position Highlights

Hybrid position with some travel involved

Job Description:

You Belong at Avera

Be part of a multidisciplinary team built with compassion and the goal of Moving Health Forward for you and our patients. Work where you matter.

 

A Brief Overview

Responsible for ensuring accurate clinical documentation, assessment and Minimum Data Set ("MDS") coding to support appropriate reimbursement. This role blends strong clinical expertise with regulatory knowledge and analytical skills. This role will oversee compliance, accuracy and optimization of clinical reimbursement strategies for the LTC Division as well as clinical reimbursement compliance and overarching MDS support to teams across Avera.

What you will do

• Maintains knowledge of federal regulations, practice standards, and procedures, as well as guidelines pertaining to the RAI process. Develop division strategies for maximizing reimbursement for PDPM, Managed Care and other payer models.


• Utilizes clinical judgement and nursing process to be a resource for Nurse Assessment Coordinators, Interdisciplinary team members and LTC Leaders. Develops strategies for maximizing reimbursement under PDPM, Managed Care and other payer models.


• Partners with payor contracting on Managed Care/ACO contract utilization and ensures facilities adhere to payer guidelines, timely filing requirements, and pre-authorization processes.


• Audits and implements action plans to improve staff education/competency as needed to ensure accurate and timely completion of supporting documentation and MDS assessment.


• Monitors facility schedules for timely and complete MDS data submission as per Federal, State, and other payor requirements.


• Analyzes reimbursement trends, identify deviations, implement corrective action plans through utilization of system data and analytic resources.


• Acts as a liaison between facilities, finance, MDS, nursing, and system resources to ensure accurate reimbursement levels.


• Provides ongoing operational support and guidance to facilities regarding denial management, appeals, and reimbursement strategies.


• Leads the division efforts to implement best practices for accurate capture of the data elements of the Minimum Data Set (MDS), which is the key driver of the care plan, quality measures and reimbursement programs.


• Must be willing to travel.

Essential Qualifications

The individual must be able to work the hours specified. To perform this job successfully, an individual must be able to perform each essential job function satisfactorily including having visual acuity adequate to perform position duties and the ability to communicate effectively with others, hear, understand and distinguish speech and other sounds. These requirements and those listed above are representative of the knowledge, skills, and abilities required to perform the essential job functions. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential job functions, as long as the accommodations do not cause undue hardship to the employer.

Required Education, License/Certification, or Work Experience:

• Registered Nurse (RN) - Board of Nursing An active license in the state of practice Upon Hire and
• Resident Assessment Coordinator - Certified (RAC-CT) - American Association of Post-Acute Care Nursing (AAPACN) An active certification by AAPACN or another approved certification agency to ensure knowledge of clinical assessment and care planning, completion of the MDS, and the regulatory body surrounding the RAI/MDS process within 180 Days
• Strong leadership and communication skills with the ability to train and mentor teams

Preferred Education, License/Certification, or Work Experience:

• Bachelor's
• Extensive knowledge of Medicare, Medicaid, PDPM, Managed Care, QM, and CMI reimbursement systems
• Strong expertise in MDS processes, including completion, regulatory compliance
• Regional MDS experience
• Proficiency in analyzing reimbursement trends, auditing, and implementing performance improvements

Expectations and Standards

• Commitment to the daily application of Avera’s mission, vision, core values, and social principles to serve patients, their families, and our community.


• Promote Avera’s values of compassion, hospitality, and stewardship.


• Uphold Avera’s standards of Communication, Attitude, Responsiveness, and Engagement (CARE) with enthusiasm and sincerity.


• Maintain confidentiality.


• Work effectively in a team environment, coordinating work flow with other team members and ensuring a productive and efficient environment.


• Comply with safety principles, laws, regulations, and standards associated with, but not limited to, CMS, The Joint Commission, DHHS, and OSHA if applicable.

Benefits You Need & Then Some

Avera is proud to offer a wide range of benefits to qualifying part-time and full-time employees. We support you with opportunities to help live balanced, healthy lives. Benefits are designed to meet needs of today and into the future.

• PTO available day 1 for eligible hires.

• Up to 5% employer matching contribution for retirement

• Career development guided by hands-on training and mentorship