Director of Clinical-Reimbursement Svcs

The Director of Clinical Services and Reimbursement partners with the clinical teams to ensure systems are in place to develop and enhance clinical services, reimbursement tools, and care delivery systems.

This is a remote position with some travel throughout our organization. Must reside in North Carolina. 

Essential Functions
The Director of Clinical Services and Reimbursement, in accordance with Federal and State standards and regulations, organizational and facility policies, philosophies, and objectives, will:

1. Review Quality Indicator Reports for each Community quarterly and when survey window opens with on-site visits to review areas of concern.
2. Collect information at facilities via audits, surveys, and observations to determine communities’ performance and compliance with standards of practice. Prepare written summary of findings and recommendations, as requested or indicated.
3. Investigate care concerns related to quality measures, Trend Tracker data, survey issues, and unusual incidents or accidents. Review related documentation and follow-up on plans of action.
4. Assist with training of new DON’s and other members of nursing as needed.
5. Assist with electronic medical records implementation and MDS training, including development of programming related to electronic medical records.
6. Using federal and state RUG/MDS guidelines, develop care strategies that will enhance patient care health and wellbeing and maximize reimbursement.
7. Assist with licensure and certification surveys as requested.
8. Using federal and state MDS/RUG guidelines, develop care strategies that enhance patient health and well-being, and maximize reimbursement opportunities.
9. Assist with the coordination and timely completion of the medical review process as needed.
10. Stay informed of federal and state policy changes which may affect service delivery and reimbursement.
11. Coordinate LSC – wide initiatives and program implementation as assigned; provide guidance and support and counsel community staff. Work with communities to ensure person centered programs are implemented and sustained.
12. Participate in the dissemination of information and training as assigned. Support communities with development and implementation of clinical training programs.
13. May be required to serve as interim DON as necessary to fill vacancies.
14. Conduct Mock Regulatory Surveys to assist communities with survey readiness and identify areas of opportunity for communities to work on and advise changes to policies and practices to ensure federal and state regulatory compliance.
15. Review and evaluate nursing services in accordance with LSC’s established policies, procedures, and processes. Assist with the development and revision of policies, procedures, and practices.
16. Assist Administrators with risk management and assessment of resident care issues.
17. Serve as the infection prevention liaison for all senior communities. Conduct periodic infection control rounds to ensure policies and procedures are followed.
18. Develop initiatives to improve clinical efficiency, quality, and compliance and promote consistency across senior communities.
19. Provide clinical leadership and support to communities as needed.
20. Assist with Medicare and Case Mix Validation Audits to assure accuracy for MDS coding and reimbursement. Assist the interdisciplinary team with the development of action plans to improve clinical reimbursement.
21. Ensure Medicare certification/recertification procedures are in place.
22. Monitor and assess MDS submissions and assist clinical staff to ensure assessments are coded accurately to present a complete picture of residents’ clinical status and services rendered.
23. Conduct periodic review of the nursing restorative programs in each home.
24. Coordinate medical reviews and assist with processes as needed. Stay informed of federal and state policy changes, which may affect medical review, service delivery and reimbursement.
25. Assist with group purchases for clinical supplies as assigned. Assist communities with formulary adherence; advise facilities as needed.
26. Participate in statewide initiatives and applicable committees.
27. Assist in the hiring and training of key nursing personnel, including but not limited to, Director of Nursing, Assistant Director of Nursing, MDS Coordinator, and Staff Development Director.
28. Significant travel time in excess of 50% with overnight stay may be required.

Supervisory Responsibilities, if any: supervise Nurse Consultants