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Royal Health Group Clinical Reimbursement Manager in Pembroke, Massachusetts

Title:Clinical Reimbursement Manager



Facility Name:Royal Health Group

Location:MA - Pembroke

Region:South Shore


Royal Health Group is looking for a (Full Time) Experienced Clinical Reimbursement Manager to float to our different facilities.

Job Description:

Clinical Reimbursement Manager is responsible to oversee the "Resident Assessment Instrument" process to ensure accurate and timely completion of resident assessments in accordance with Medicare, Medicaid, OBRA and other payor program requirements (MMQ).


  • Performs ongoing audits to ensure an appropriate reimbursement level for each resident. Evaluates care to ensure that services and products match benefits available

  • Reviews medical records, care plans, charting to ensure documentation supports care provided and reimbursement level.

  • Monitors facility practice to ensure compliance with guidelines for participation in Medicare, Medicaid and other benefit programs. Initiates action needed to ensure compliance.

  • Participates in triple check prior to release of claims. Tracks and reviews all claim denials to identify problems.

  • Prepares and timely submits any additional development requests, reconsideration and administrative law judge hearings.

  • Review state MDS validation reports to identify issues and or processes to ensure accuracy of submitted MDS’s.

  • Responsible for evaluating and providing education, intervention and support for Medicare, PPS, RAI, state specific and special contract reimbursement.

  • Oversee the overall process of reimbursement for facilities.

  • Audit Medicare/Medicaid case-mix documents in order to assure appropriate reimbursement for services provided within the facility.

  • Participates in the pre-admission process to ensure essential information needed for MDS/Case mix optimization is obtained from the referral source.

  • Performs modifications of assessments in accordance with CMS Correction Policy.

  • Other duties as assigned

Job Requirement:

  • 3 years of Clinical Reimbursement experience at the Regional level strongly preferred

  • Matrix/PCC/Optima/Casamba experience preferred

  • Excellent customer service skills; dedication and commitment to providing excellent healthcare services to our residents, patients and family members

  • Excellent ability to operate effectively and efficiently in an enthusiastic, team-oriented work environment

  • comprehensive knowledge of Medicare and Medicaid reimbursement

  • Ability to quickly recognize and identify symptoms and make decisions based on changes in acuity level

  • Exceptional organization skills and detail-oriented

  • Travel throughout MA/RI

Equal Opportunity Employer

Royal Health Group provides equal employment opportunities (EEO) to all employees and applicants for employment without regard to race, color, religion, sex, national origin, age, disability, or genetics. In addition to federal law requirements, Royal Health Group complies with applicable state and local laws governing nondiscrimination in employment in every location in which the company has facilities.