Care Management Specialist

Primary Responsibilities

Responsible for the coordination of the Resident Assessment Instrument (RAI) process to ensure accurate and timely completion of resident assessments in accordance with Medicare, Medicaid, OBRA and other payer program requirements. Ensures assessments accurately reflect the physical, mental and psychosocial status of each resident; ensures appropriate documentation to report and support services provided and assessment accuracy. Communicates effectively with other members of the interdisciplinary team.

Follows all RIHS policies and procedures.

Essential Functions

• Ensures timely, accurate, and complete assessment of the resident’s health and functional status during the entire assessment period. **
• Participates in the pre-admission process to ensure essential information needed for MDS/Case Mix optimization is obtained from the referral source(s).
• Ensures accurate and timely completion of all Medicare/Medicaid case-mix documents to assure appropriate reimbursement for services provided within the facility.
• Works in collaboration with the facility Director of Rehab to ensure the most appropriate assessment reference date (ARD) is utilized for Medicare/Managed Care Assessments.
• Tracks Skilled (MRA/MCO/MCG/MMP) customers utilizing Case Management Tools to determine continued and appropriate Medicare/Managed Care eligibility and benefit period through regular communications with Regional Care Management Specialist, Business Office and external Case Managers.
• Gathers information needed for Managed Care Utilization Reviews throughout the resident’s stay and communicates this with the Managed Care organization’s Case Manager as required.
• Ensures that additional requirements of the Medicare Program are met, such as Physician certification and re-certification.
• Performs concurrent MDS review to assure appropriate RUGs category is achieved through the capture of appropriate clinical information.
• Participates in the interdisciplinary team process to communicate opportunities, facilitate efficient and effective care plan development and management.
• Ensures the accurate and timely completion of all MDS assessments including PPS, Unscheduled, Admission, Quarterly, Annual, and Significant Change in compliance with RAI guidelines.**
• Collaborates with the interdisciplinary team to identify significant change in status and implementation of Significant Change in Status MDS. **
• Maintains an accurate schedule of all MDS assessments to include the proper reference dates throughout the resident’s stay.
• Tracks, records, and analyzes all default days and rectifies if appropriate. Implements corrective action to prevent further default action.
• Performs Modification/Inactivation of assessments in accordance with CMS Correction Policy and collaboration with Regional Care Management Specialist.
• Conducts regular audit of MDS process including validation of coding documentation, evaluating outcomes, and utilization of Data Integrity Audit reports (Point Right) per company policy.
• Ensures the timely electronic submission of all Minimum Data Sets and secures back-up personnel to complete this process.
• Reviews the Validation reports and ensures that appropriate follow-up action is taken.
• Reviews Late/Missed assessment reports monthly and addresses issues as appropriate.
• Reviews QM and SNF QRP reports monthly and ensures that appropriate follow up action is taken.
• Communicates with the Business Office Manager and Administrator on a regular basis regarding RUG distribution, default days/unassigned days, case mix index (if applicable) and their reimbursement impact.
• Participates in daily Case Management, weekly Level of Care, monthly Triple Check, and other meetings per RIHS policy. Assists in the preparation and timely submission of any Additional Development Requests (ADRs), Reconsideration and Administrative Law Judge (ALJ).
• Functions as an RAI and Care Management resource to the facility staff.
• Utilizes AIS as annual competency training as well as for educational resource as needed.
• Assists in the orientation and training of new associates on the RAI process and ensures the dissemination of any new or updated materials regarding the RAI and/or Federal and State regulations.

Other Duties

• The Care Management Specialist manages the day to day operations of the department.
• Maintains current knowledge of reimbursement regulations.
• Maintains data in an organized, easily retrievable manner.
• Maintains good personal hygiene and follows dress code requirements.
• Communicates regularly with the Regional Care Management Specialist to discuss identified clinical reimbursement issues.
• Ability to work flexible work hours to support business requirements.
• Ability to utilize both local and corporate resources in the execution of job responsibilities.
• Must possess superior clinical assessment and documentation skills.
• Must demonstrate strong interpersonal skills and ability to work well in a team environment.
• Other duties as assigned or needed.

Key Competencies

• Analytical reasoning
• Logical reasoning
• Problem solving
• Time management
• Organizational skills
• Research skills
• Language Skills
• Must possess excellent verbal and written communication and presentation skills

Educational/Training Requirements

• Must be a graduate of an accredited school of nursing with current R.N. or L.V.N.
• ** Position may be filled by LVN, however specific job functions denoted by "**" will require an RN to Coordinate the process as stipulated by Federal Regulations.
• Complete and pass all RIHS specific MDS/RUGs training modules (AIS) within the first 90 days of employment and ongoing per company policy.
• Competency with standard office software applications as well as software applications related to MDS/RAI processes.
• High initiative and ability to efficiently and effectively lead interdisciplinary teams and coordinate and manage RAI process.

Licensing Requirements

• Licensure in the state in which employment occurs.

Experience Requirements

• Minimum of two years health care experience.
• Experience with MDS completion, reimbursement, clinical resource utilization and/or case management is highly desirable.

Physical Demands

The physical demands described here are representative but not necessary all inclusive, of those that must be met by an employee to successfully perform the essential functions of this job. While performing the duties of this job, the employee is regularly required to effectively communicate. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

Regency Integrated Health Services is an Equal Opportunity Employer.  Regency does not discriminate on the basis of race, religion, color, sex, gender identity, sexual orientation, age, disability status, national origin, veteran status or any other basis covered by appropriate law.  All employment decisions are based on legitimate, non-discriminatory criteria.