Oversees, reviews and/or completes the PRI and MDS/PPS components of the facility based MDS/PPS/PRI/QI Program. Attends program education/training sessions for PRI certified assessors, assists with on sight completion/review for quarterly and full house PRI submissions. Completes all Medicare PPS MDS’s for both subacute and long-term care. Establishes the schedule for completion of the Medicare required assessments setting the completion date to maximize reimbursement and RUGS categories for each individual assessment. Acts as support/liaison to the Director of Nursing Services in determining eligibility for Medicare and tracking Medicare days in the facility. Consults with Clinical Management Systems Department regarding training and audit results. Serves as facility contact for third part payors to ensure coverage under the HMO contracts.
1. Assist in development of and attend training program for PRI RUGS II compatible with State Codes, Rules and Regulations, ElderWood standards and software requirements.
2. Participate in completion of the quarterly and semi annual full house PRI’s to ensure maximization of RUGS II classifications and reimbursement.
3. Complete the Medicare required assessments and set the schedule for completion in accordance with Federal Codes, Rules and Regulations to ensure maximization of RUGS III scores and reimbursement.
4. Act as support/liaison to the Director of Nursing Services to determine eligibility for Medicare and tracking of Medicare participants in the facility.
5. Provide ongoing in-service, updates, and oversight of the facility PRI Program and the Medicare PPS Program.
6. Assist the Clinical Management Systems Department in developing assessment tools and reviewing processes for implementation at the facility level.
7. Attend, participate in and present education seminars pertinent to the Medicaid RUGS II Program and the Medicare RUGS III Program.
8. Attend resident review meetings for the Subacute Unit and resident RCP Meetings for long term care units as appropriate/required.
9. Provide written reports regarding resident case mix, RUGS II/III Categories, facility Medicare days, reimbursement days and categories, and other reports as requested and/or required.
10. Assist clinical staff with documentation for both RUGS II and RUGS III to ensure appropriate classification of residents for reimbursement.
11. Complete and/or train others to complete Certificate of Medical Necessity accurately to insure facilities ability to bill Medicare Part B for enteral and urological services.
12. Serve as facility contact for Third Party Payors/designated HMO contractors to ensure appropriate coverage/reimbursement.
13. Provide Third Party Payors with documentation required for coverage/reimbursement.
14. Secure prior authorization as necessary for continued coverage under HMO contract.
15. Notify Third Party Payors when authorized services our no longer provided by the facility.
16. Handle financial, personnel and medical records or other company information in a confidential manner.
17. Attend staff meetings and required or preferred in-service training.
18. Generate and develop ideas, which improve the quality of care for residents or increase job productivity and satisfaction. Encourage involvement and recognize staff for making exceptional contributions.
19. Perform all job duties according to safety rules and practices required for this job position, and as required to ensure the general safety of staff, residents and visitors of this facility.
20. Perform assigned duties according to the service excellence standards and goals established for this job position, and for all staff members of this facility.
21. Exhibit the highest level of customer service towards staff, residents, and visitors and assure that all staff do the same.
22. Perform other work duties as requested by Administrator/Management.
1. Registered Professional Nurse, licensed in New York State.
2. Preferred Certification in PRI Assessment and possession of a New York State PRI Assessor Number.
3. Knowledge of PRI/MDS/PPS software, completion, coding and submission requirements.
4. Adult teaching experience essential.
5. Excellent verbal and written communication skills.
6. Demonstrated knowledge of NYS Medicaid Program, RUGS II Classification Systems; Medicare/PPS Program, RUGS III Classification/Reimbursement Systems; ElderWood Medical Records Systems and documentation requirements.