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Next Step Health Care Clinical Reimbursement Specialist in Woburn, Massachusetts

Next Step Healthcare is seeking an experienced Clinical Reimbursement Specialist to support our MDS/MMQ teams in Massachusetts.

The Clinical Reimbursement Specialist provides extensive training, analysis, advice and consultation to the facilities and 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 makes 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.

Full-time; home office based position with 3-4 travel days per week.

Job Functions include but are not limited to:

  • Provides consultation, training and support concerning the Medicare, Managed Care and state case mix payment system 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.

  • Recognizes, advises and promotes facility best practices and systems for dealing with state case mix/Medicare and Managed Care payment systems.

  • Studies, analyze and reports period over period information and systems in order to identify trends and deviations from results in Medicare, Managed Care and State Case Mix Index and takes appropriate actions.

  • Works in conjunction with 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.

  • Assists in the recruitment/interview process for MDS and MMQ vacancies.

    Qualifications:

  • Licensed as a Registered Nurse in the State of Massachusetts

  • Three to Five years of clinical experience in a long-term care setting, which includes supervisory, administrative or consultative capacities.

  • Current knowledge of computer technology and systems.

  • Ability to work independently with minimal supervision and guidance.

  • Extensive knowledge of MDS and back-up documentation required and extensive knowledge of state grouper and calculator field relative to MDS and state payment.

  • Extensive knowledge of Medicare reimbursement, RUG IV system, compliance and eligibility.

  • Must be willing and able to travel extensively and maintain a valid driver’s license.

    We offer competitive compensation and benefit plans including:

  • Vacation, sick and holiday pay

  • Medical, Dental, Vision Insurance

  • ST/LT Disability Insurance

  • Tuition Reimbursement

  • Life Insurance

  • 401K

    At Next Step Healthcare, we know that working in the healthcare industry is more than just a job – it’s a way of life reserved for the most compassionate, caring, and hard-working individuals. Are you ready to take the next step in your career? Apply today.

    Next Step Healthcare is an equal opportunity employer. We embrace diversity and are committed to fostering an inclusive workplace for all employees.

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