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Case Mix Specialist

Ohio 000 - Ohio, any location, Any, OH
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ProMedica is a mission-based, not-for-profit health and well-being organization headquartered in Toledo, Ohio. It serves communities in 28 states. The organization offers acute and ambulatory care, an insurance company with a dental plan, and post-acute and academic business lines. The organization has more than 49,000 employees, 12 hospitals, 2,500+ physicians and advanced practice providers with privileges, 1,000+ healthcare providers employed by ProMedica Physicians, a health plan, and senior care services.


ProMedica`s senior care division, formerly known as HCR ManorCare, operates 335+ assisted living facilities, skilled nursing centers, memory care communities and hospice and home health care agencies. Services are provided in 26 states and currently operate under the brand names Heartland, ManorCare, ProMedica and Arden Courts. Over the next 18 months, the senior care entities will begin to rebrand to ProMedica.


Driven by its Mission to improve your health and well-being, ProMedica has been nationally recognized for its advocacy programs and efforts to address and lead in social determinants of health, champion healthy aging and cultivate innovative solutions. For more information about ProMedica senior care services, please visit www.promedicaseniorcare.org.


Description

Responsible to review Medicare/Medicaid documentation to assist nursing centers in completing MDS 3.0 documentation to assure appropriate levels of Medicare and/or Medicaid reimbursement. 

Responsibilities:

  1. Reviews MDS 3.0 documentation for accuracy and appropriateness; Audits resident’s chart to monitor that services match resident needs and documentation reflects categories for case mix reimbursement.
  2. Monitors LTCQ reports for accuracy of MDS coding.
  3. Monitors and assists with validation of Quality Indicator reports for accuracy of MDS coding.
  4. Responsible for accuracy of MA Picture Date process for each assigned center.
  5. Assists Director, Case Mix Reimbursement with developing training materials for quarterly MDS training sessions.  Presents information at quarterly MDS training sessions.
  6. Monitors that facilities follow Medicare/Medicaid regulatory and HCR ManorCare reimbursement guidelines.
  7. Assists nursing staff in improving MDS assessment skills through formal and informal training.  Coordinates training and communication with Clinical Services staff as needed. 
  8. Performs audits per company and divisional standards and policies.  Reviews required documentation tools; for example, RUG III Billing Log, to ensure appropriate levels of reimbursement. 
  9. Monitors Corporate Compliance policies and notifies appropriate facility, regional, divisional, and corporate staff as needed.  
  10. Attends and participates as needed in regional meetings, scheduled in-service programs, staff meetings and other center meetings and sits on required committees.
  11. Participates in assisting facility staff with interview of ADON of Clinical Documentation and MDS Coordinator. 
  12. Participates in developing and updating Medicare PPS and Case Mix policies and procedures. 
  13. Completes and maintains records and reports as required.
  14. Coordinates and promotes work between departments; Maintains confidentiality of necessary information.
  15. Collaborates with corporate and/or facility staff related to denial issues affected by the MDS.
  16. Works with facility, corporate and regional support staff to assure appropriate levels of reimbursement.
  17. Monitors submission requirements according to Federal and State standards.
  18. Monitors to assure the complete and timely submission of MDS data according to Federal and State reimbursement requirements.
  19. Collaborates with the facility to keep them informed of new developments for Federal and State payment systems.
  20. Remains abreast of regulatory change for Medicare/Medicaid reimbursement and communicates necessary information to appropriate personnel. 
  21. Communicates and coordinates the resolution of facility issues through appropriate regional and corporate departments.
  22. Performs any miscellaneous work assignments as may be required.

Educational Requirements

Graduate of an approved Registered Nurse program and RN licensed in the state of practice required.

Position Requirements

Minimum of 2 years of nursing experience in a Skilled Nursing Facility preferred. Excellent knowledge of Case-Mix, the Federal Medicare PPS process, and Medicaid reimbursement, as required. Thorough understanding of the Quality Indicator process. Knowledge of the OBRA regulations and Minimum Data Set. Knowledge of the care planning process.

Job Specific Details:

Cleveland and Toledo market

Category

Nurse Manager

Posting ID

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*Equal Opportunity Employer*

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