Position Summary
The Clinical Reimbursement Specialist is an on-site facility resource responsible for coordinating and monitoring the Minimum Data Set (MDS), resident assessment, care-planning, skilled coverage, and reimbursement processes. The position works directly with the Administrator, Director of Nursing, MDS team, therapy, Business Office, medical providers, and interdisciplinary team to ensure that resident assessments are accurate, timely, clinically supported, and compliant with Medicare, Medicaid, managed care, the Patient-Driven Payment Model (PDPM), and applicable federal and state requirements.
The specialist maintains daily visibility into facility admissions, payer changes, clinical changes, assessment schedules, documentation quality, authorization requirements, and reimbursement risks. The role supports appropriate reimbursement only when it is fully supported by the resident’s condition, services provided, and the medical record.
Essential Duties and Responsibilities
1. MDS and Assessment Coordination
- Maintain the facility MDS assessment calendar and monitor all assessment reference dates, completion dates, transmission deadlines, and required corrections.
- Coordinate comprehensive, quarterly, significant-change, significant-correction, entry, discharge, and Medicare assessments in accordance with the RAI Manual and CMS requirements.
- Review MDS coding for consistency with the resident’s current condition, diagnoses, functional status, clinical services, therapy services, restorative programs, and supporting documentation.
- Monitor Care Area Assessments, care-plan development, and interdisciplinary participation to ensure identified needs are addressed and documentation is complete.
- Track rejected submissions, validation reports, warning messages, late assessments, modifications, and inactivations through resolution.
- Provide coverage or direct assistance with MDS completion when operationally necessary and within the employee’s licensure and competency.
2. Clinical Reimbursement and PDPM Oversight
- Review Medicare Part A, Medicare Advantage, Medicaid, managed care, and other payer-related clinical documentation and reimbursement requirements.
- Validate PDPM components, including diagnoses, nursing classification, functional scoring, non-therapy ancillary services, speech-language pathology factors, and therapy utilization, as applicable.
- Monitor admissions, hospital returns, changes in condition, payer changes, interrupted stays, and other events that may affect assessment or reimbursement requirements.
- Identify potential missed reimbursement, unsupported coding, documentation inconsistencies, or compliance risks and promptly communicate findings to facility leadership.
- Participate in Triple Check and other pre-billing reviews to validate census, covered days, payer source, assessment completion, physician certification, authorization, and supporting documentation.
- Collaborate with the Business Office and managed care personnel to monitor authorizations, continued-stay reviews, notices, denials, and appeal deadlines.
3. Clinical Documentation Review
- Conduct routine concurrent and retrospective medical record audits to verify that documentation supports skilled coverage, medical necessity, diagnoses, MDS coding, services rendered, and reimbursement.
- Review nursing documentation, physician and practitioner notes, hospital records, therapy documentation, medication and treatment records, restorative nursing records, care plans, and other supporting assessments.
- Identify documentation gaps, conflicting information, copy-forward concerns, incomplete records, or untimely entries and provide clear corrective guidance.
- Promote resident-specific documentation that describes the resident’s condition, risks, skilled needs, interventions, progress, response to treatment, and discharge potential.
- Follow up on identified deficiencies to verify timely correction and sustained improvement.
4. Compliance, Auditing, and Quality Improvement
- Maintain current knowledge of CMS requirements, the RAI Manual, PDPM, Medicare coverage criteria, Medicaid case-mix requirements, managed care rules, and applicable state regulations.
- Conduct scheduled and focused audits based on facility risk, survey findings, denials, quality trends, late assessments, or leadership direction.
- Assist with additional documentation requests, medical reviews, payer audits, denials, appeals, and reimbursement-related inquiries.
- Develop written findings, corrective action recommendations, education plans, and follow-up monitoring when deficiencies are identified.
- Participate in the Quality Assurance and Performance Improvement process and present reimbursement, assessment, and documentation trends as assigned.
- Maintain resident confidentiality and comply with HIPAA, privacy, security, infection-control, and facility policies.
5. Key Performance Expectations
- MDS assessments are completed, transmitted, and corrected accurately and within required timeframes.
- PDPM and case-mix classifications are accurate and supported by resident-specific clinical documentation.
- Skilled coverage and medical necessity documentation are complete, timely, and consistent across disciplines.
- Triple Check and pre-billing reviews are completed before claim submission, with identified discrepancies resolved or escalated.
- Assessment rejections, late submissions, reimbursement denials, and repeat documentation deficiencies are reduced.
- Facility staff receive timely education, practical feedback, and follow-up support.
- Audit findings and corrective actions are documented, communicated, and monitored through completion.
6. Required Qualifications
- Current, active Registered Nurse license in the state of practice is preferred. A Licensed Practical Nurse with substantial MDS and skilled nursing reimbursement experience may be considered based on facility requirements.
- Minimum of three years of MDS, clinical reimbursement, utilization review, or skilled nursing experience.
- Working knowledge of MDS 3.0, the RAI process, PDPM, Medicare Part A, Medicare Advantage, Medicaid reimbursement, managed care, skilled documentation, and care planning.
- Experience completing, reviewing, or auditing MDS assessments and supporting clinical records.
- Proficiency with electronic medical record systems, MDS software, Microsoft Office, and basic spreadsheet reporting.
- Strong analytical, organizational, communication, education, and problem-solving skills.
- Ability to manage multiple deadlines, maintain confidentiality, and exercise sound clinical and compliance judgment.
