MDS RN

ESSENTIAL DUTIES AND RESPONSIBILITIES:
• Provides education and assistance to facilities on Medicare/Medicaid related areas including eligibility,
certification, coverage, documentation, utilization and reimbursement. Assists facilities with initial
certification procedures and follow-up of problem areas.
• Interacts with Medicare, Managed Care and Medicaid claims review unit and compliance unit to assist a
facility in complying with company procedures and federal, state and local regulations. Reports regularly
to administration on issues and activities. Interacts with the Medicare and managed Care intermediaries
in areas of coverage and documentation. Assists in review and preparation of denied claims or
administrative record reviews by outside intermediaries.
• Completes and assesses compliance with Medicare, Managed Care, Medicaid and third party payers and
company procedures. Establishes systems and programs designed to correct any non-compliance
situation. Participates with any outside reimbursement audits to acquire first-hand knowledge of areas
that might lead to system failures.
• Establishes and maintains current statistical data associated with the Medicare, Managed Care and
Medicaid programs by region. Cooperates with operations to monitor activities for contractor programs,
i.e. therapies, utilization review. Reviews and maintains Medicare, Managed Care and Medicaid
reference materials.
• Monitors and identifies utilization issues. Establishes systems and programs to maximize utilization and
reimbursement. Monitors compliance with third party policies and procedures for authorizations for
payment and provision of services.
• Provides ongoing orientation and training to appropriate facility staff regarding the Medicare, Managed
Care and Medicaid and other contracted third party payers. Provides education regarding changes in any
reimbursement program.
• PDPM reviews upon admission or re-admission or as indicated
• Review of MDS completion for Medicare A MDS’ for compliance and accuracy
• Gathers documentation for CMS audit requests and other audits as indicated
• Reviews physician documentation for accurate ICD 10 coding, assisting to set and rank diagnosis for new
admissions and re-admissions
• MDS Integrity reviews as indicated.
• MDS completion as needed
• Other duties as assigned