Summary/Objective In keeping with our organization's goal of improving the lives of the Residents we serve, the VP of Clinical Reimbursement assures the management of the Medicare, Medicaid, and all 3rd party billing (Managed Care). This position is responsible for regulatory compliance and quality improvement efforts to ensure that the facilities maximize the reimbursement to which they are entitled. This position serves as a role model for ethical business practices, a consultant for assigned facilities and works to ensure that the services offered exceed federal, state, and company standards.
The VP of Clinical Reimbursement will encompass and hold responsibility for the functions listed below as well as all job functions for the Regional Assessment Coordinator.
Essential Functions Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
Engage facility management team in problem solving processes to identify opportunities for improvement pertaining to facility reimbursement.
Work with staff that coordinates the case mix submission process to ensure maximum legitimate reimbursement provided for services delivered to residents in each facility.
Clear understanding of reimbursement methodology with regards to Medicare, Medicaid, and Managed Care Plans, (in all applicable facilities).
Constantly improving the UR process and ensure a smooth weekly meeting.
Must attend at least 1 UR meeting at each building, per month. This will allow this position to gain a clear understanding of UR process in each facility.
Staying up-to-date with all industry updates and regulation changes.
Provides a high-level of technical competency and serves as a subject matter expert regarding documentation, coding, billing, reimbursement, and compliance management.
Provide leadership and training for multiple MDS Coordinators, ensuring standards of practice are uniformly implemented across the corporation.
Conduct educational in-services as needed.
Responsible for ADR process and developing the tracking tools to manage this process. Ongoing; ensuring these tools are utilized/revised for optimal outcomes.
Implement and direct Medicare/Medicaid/Managed Care auditing and systems review for:
Clinical documentation requirements
Strategic selection of assessment reference dates
Provide interdisciplinary team training for:
MDS and PCC training
Physician Certification completion
Managed Care Contracts and updates
Financial Analysis: Review corporate reports for trends, monitors outcomes and directs facility in improving outcomes in the following areas:
Daily RUGs distribution
Length of stay analysis
Assist in Part B program development
30-day readmission rates to individual hospitals and company at large
Clinical Analysis: Implements and maintains processes related to reimbursement.