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ProMedica Health System Clinical Reimbursement Specialist - MDS in San Francisco, California

The Clinical Reimbursement Specialist is responsible to review Medicare/Medicaid documentation to assist nursing centers in completing MDS to ensure appropriate levels of Medicare and/or Medicaid reimbursement. Works with RDOs, Administrators, and facility staff in training/consulting on traditional Medicare A coverage, documentation, and eligibility. As part of a regional team (MRBS, RRM, CMS), assists with monitoring medical records requests for M2 and Managed Medicaid payers to ensure they are tracked and responded to in a timely manner. This role will cover skilled nursing facilities in the Washington and Colorado regions and candidates must live in that area.


  • Monitors that facilities follow Medicare/Medicaid regulatory and HCR ManorCare guidelines.

  • Remains abreast of regulatory change for Medicare/Medicaid reimbursement and communicates necessary information to appropriate personnel.

  • Reviews MDS documentation for accuracy and appropriateness

  • Monitors and assists with validation of Quality Measures report for accuracy of MDS coding.

  • Assists with developing and presenting training materials for MDS training sessions. .

  • Participates in interviews of DCD and MDS Coordinators.

  • Performs audits per company standards and policies to ensure appropriate levels of reimbursement.

  • Monitors Corporate Compliance policies and notifies appropriate facility, regional, divisional, and corporate staff as needed.

  • Collaborates with corporate and/or facility staff related to denial issues affected by the MDS.

  • Collaborates with the facility to keep them informed of new developments for Federal and State payment systems.

  • Coaches facility ADNS, Administrators, and other staff as to proper procedures for M2 medical records requests, and Part A ADRs and Appeals.

  • Makes recommendations regarding eligibility and coverage for Medicare Part A.

  • Monitors M2 (Medicare, Managed Care) and Managed Medicaid records requests, with the regional team, to ensure they are tracked and responded to in a timely manner.

    000 - California, any location

Minimum of 2 years of nursing experience in a Skilled Nursing Facility preferred. Excellent knowledge of Case-Mix, the Federal Medicare PPS process, and Medicaid reimbursement, as required. Thorough understanding of the Quality Indicator process. Knowledge of the OBRA regulations and Minimum Data Set. Knowledge of the care planning process.

Equal Opportunity Employer Qualified applicants will receive consideration for employment without regard to race, color, national origin, ancestry, religion, sex/gender (including pregnancy), sexual orientation, gender identity or gender expression, age, physical or mental disability, military or protected veteran status, citizenship, familial or marital status, genetics, or any other legally protected category. In compliance with the Americans with Disabilities Act Amendment Act (ADAAA), if you have a disability and would like to request an accommodation in order to apply for a job with ProMedica Senior Care, please contact jobline@hcr-manorcare.com.