Registered Nurse - Clinical Reimbursement Specialist (MDS)

The Clinical Reimbursement Director is responsible for assisting Resident Assessment Instrument (RAI) process to ensure accurate and timely completion of resident assessments in accordance with Medicare, Medicaid, OBRA and other payor program requirements.


Case Management

 Manages Medicare Part A and Part B certification process.

 Performs ongoing evaluations from pre-admission through discharge to ensure an appropriate reimbursement level for each resident. Evaluates care to ensure that services and products match benefits available

 Reviews medical records, care plans, charting to ensure documentation supports care provided and reimbursement level.

 Monitors facility practice to ensure compliance with guidelines for participation in Medicare, Medicaid and other benefit programs. Initiates action needed to ensure compliance.

 Participates in quad check prior to release of claims. Tracks and reviews all claim denials to identify problems.

 Assists in preparation and timely submission of any additional development requests, reconsiderations and administrative law judge hearings.

 Review state MDS validation reports to identify issues and or processes to ensure accuracy of submitted MDS’s.

 Responsible for evaluating and providing education, intervention and support for Medicare, PPS, RAI, state specific and special contract reimbursement.

 Manage the overall process of reimbursement for the facility.

 Track all Medicare/Medicaid case-mix documents in order to assure appropriate reimbursement for services provided within the facility.

 Other duties as assigned

RAI Process

 Initiates and completes discharge and re-entry tracking forms accurately and timely.

 Performs modifications of assessments in accordance with CMS Correction Policy.

 Verifies timely transmission of MDS assessments, including tracking forms to the State in accordance with standards.

 Other duties as assigned

Job Requirements:


 Knowledge and understanding of regulatory processes (Federal, and/or State Regulations)

 Knowledge of the RAI Regulations

 Knowledge of principles and processes for providing customer service. This includes customer needs assessment, meeting quality standards for services, and evaluation of customer satisfaction.


 Effective verbal and written communication skills

 Understanding written sentences and paragraphs in work related documents.

 Actively looking for ways to help people.

 Communicating effectively in writing as appropriate for the needs of the audience.


 Ability to work in a “Matrix” management environment

 The ability to listen to and understand information and ideas presented through spoken words and sentences.

 Ability to relate positively, effectively, and appropriately with residents, families, community members, volunteers, and other facility staff. Possess special interest in working with long-term care residents and the elderly.


 Computer literacy skills (Microsoft Outlook, Microsoft Office, Internet)

 High School Diploma

 One to three years of professional experience and/or training; or equivalent combination of education and experience.


 Licensed Registered Nurse (RN) Required

 CPR Certified

We are an Equal Opportunity Employer and Drug Free Work Place

Come join our TEAM, apply today!

Full time
Sanford, FL 32771, US