Clinical Reimbursement Review Nurse

Clinical Reimbursement Review Nurse is responsible for data collection and data entry that represents the residents’ level of care requirements into the utilization software for Maryland Medicaid, in accordance with Federal and State guidelines for residents applying for or continuing a stay in long term care utilizing Medicaid benefits.

Duties and responsibilities of this position include, but are not limited to the following tasks and assignments:

                          A. Clinical: Responsible for the collection and data entry of elements needed to support application or continued stay in long term care utilizing Maryland Medicaid benefits.

1. Maintains a system to identify and work through cases due for review in a timely manner.
2. Reviews relevant electronic health records (EHR) such as the MDS, interdisciplinary documentation, and provider documentation and accurately enters/uploads required clinical information into the utilization software that accurately supports the resident’s level of care.
3. Reviews case mix boards and supporting documentation to ensure accurate and complete documentation for utilization software entry.
4. Identifies active diagnosis codes and relevant documentation to include in utilization software upload to demonstrate overall resident status.
5. Queries and communicates effectively with interdisciplinary team (IDT) to ensure accurate representation of resident is documented within the electronic health record. This will include daily documentation as well as evaluations, plans of care, Preadmission Screening and Resident Reviews (PASRRs) and MDS assessments.
6. Ensures that all resident assessments are completed within the allocated time frames within the utilization software.

                          B. Administrative:

1. Abides by the standards identified in FutureCare’s Statement of Corporate Ethics and the Corporate Compliance Plan.
2. Participates in Reimbursement Team Performance Improvement activities
3. Participates in developing goals for the department.
4. Assists in identifying strategies and targets dates for goal attainment.

                          C. Communication: Promotes effective relationships and communication with all staff, residents, and families.

1. Reviews changes in resident condition with the IDT to validate status prior to documenting in the utilization software.
2. Promptly communicates any concerns with a resident’s level of care to the appropriate center leadership and to the Director of Clinical Reimbursement.
3. Communicates any opportunities for improvement in electronic health record documentation to the appropriate center leadership and to the Director of Clinical Reimbursement.
4. Communicates with the Maryland Medicaid Utilization Agent as indicated to ensure timely completion of required tasks.
5. Identifies and diffuses stressful/conflict situations related to verbal and non- verbal communication problems with follow-up resolution.
6. Communicates pertinent information and requests through established channels.
7. Interacts with others in a considerate, helpful, and courteous manner.

                           D.Professional Development:  Seeks opportunities for own growth and expansion of responsibilities.

1. Attends meetings as directed.
2. Participates in education workshops/programs to increase professional competence to meet professional goals.
3. Presents a neat appearance in appropriate dress and identification as required by position.
4. Participates in self-evaluation by discussing with supervisor strengths, weaknesses, objectives, and goals.
5. Attends mandatory in-services.

• Other relevant duties as assigned.

I have read and understand the functions and requirements of this position.  I understand that this is not to be considered as an exhaustive statement of duties, responsibilities or requirements and does not limit the assignment of additional duties for this position.

1. Current Maryland or Multistate Registered or Licensed Practical nursing license (preferably with Minimum Data Set (MDS) training and experience).
2. Computer literacy is required.