Job Description

Job Description

Job Description

At MGM Healthcare, we deliver the highest quality of care for every resident through our most valuable asset: you. We seek compassionate and thoughtful individuals who share our passion for exceptional care in senior living. MGM Healthcare partners with a vast network of skilled nursing centers across 2 states to support our small team environment of caring professionals with the resources and benefits of a large enterprise. Your legacy of excellence begins when you join us at MGM Healthcare.

Summary Description:

As the Compliance Reimbursement Nurse, they will play a crucial role in ensuring the accuracy and compliance of billing and reimbursement for the centers we support. 

Essential Functions of Compliance Reimbursement Nurse:

• Possess a thorough understanding of all regulations and standards related to the RAI process (Federal regulations and MDS User Manual)
• Remain knowledgeable of CMS coverage and payment methodologies, current Medicare/Medicaid regulations and documentation requirements.
• Completes routine clinical review that thoroughly reviews resident’s medical records to verify that billing accurately reflects the care provided applying guidelines from the Medicare and Medicaid Services (CMS) and payer-provider contract terms to identify potential overpayments or underpayments.
• Document audit findings clearly and precisely, often using proprietary workflow systems.
• Provides feedback to center Administrator regarding issues identified and being addressed.
• Educate MDS Coordinators on audit findings to ensure compliance and integrity of the RAI process.
• Notifies staff or therapy of any changes that need to be made to documentation or work- flow and follow-up to see that work is completed.
• Works collaboratively with home office leadership, and center leadership to respond to routine compliance audits.
• Works collaboratively with center Billers and therapy in review of records subject to external audits such as RAC audits and in oversight of coding of records for billing.
• Maintain proficiency in the operations of the MDS software program, including the ability to transmit data per regulatory standards.
• Identify treads in compliance audits that require company policy and procedure improvement with companywide education working with Vice President of Reimbursement and Corporate Compliance Officer to implement.
• Maintain CONFIDENTIALITY of pertinent client and employee information to assure their privacy is protected.
• Other duties as assigned.

Other Duties:

·         As this job description is not intended to be all-inclusive, the employee will be expected to perform other essential functions and duties as assigned.

Qualifications of Compliance Reimbursement Nurse:

• Graduate of an accredited School of Nursing
• LPN/RN with a current, active state license.
• ICD-10 coding experience required.
• MDS experience required.
• Basic computer knowledge.
• Excellent written, verbal, and interpersonal skills.
• Exhibit excellent customer service and a positive attitude.
• Convey compassion and empathy for residents and their representatives.
• Be a skilled communicator, educator, director, and motivator.
• Have exceptional organizational and time management skills.
• Be committed to excellence.
• CPR certified.

EEO Statement:

Our facility provides equal employment opportunities. We are committed to complying with all state, federal, and local laws that prohibit discrimination in employment, including recruitment, hiring, placement, promotion, transfers, compensation, benefits, training, programs, reductions in workforce, termination, and recall. Our facility strives to provide equal opportunity for employment to all individuals who are properly qualified and able to perform the duties of their employment, without regard to employees’ legally protected characteristics (“protected class”) including: age, sex, race, color, creed, religion, national origin, ancestry, citizenship, marital status, pregnancy, medical condition, physical or mental disability, sexual orientation, gender identity, sex stereotyping, or genetic information.

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