Job description
Touchstone Communities
Director of Medical Review
Make Lives Better. Be a part of something meaningful: The Touchstone Experience.
If your purpose is to
Make Lives Better, we welcome you to
Join Team Touchstone today and be part of something meaningful. Touchstone is committed to bringing a Best In Class Healthcare Experience to our Patients, Residents and Veterans. Compassionate team members are the key to revealing our vision to be the leading post-acute healthcare solution in the markets we serve. If you desire to be part of a work environment where every voice matters, we encourage you to apply today.
The Purpose
To establish, coordinate and guide the medical review process to ensure compliance with payor, state, and federal requirements to optimize the ability to maintain profitability and minimize risk of recoupment so that clinical and financial objectives are met or exceeded.
Essential Job Functions:
Perform medical review and associated activities on claims records
Establish, coordinate and guide the medical review process to ensure compliance with payor, state, and federal requirements
Maintain and update company policies with regards to all payors appeals and denials requirements and timelines
Resource for all team members for medical records questions in regards to the appeals and denials processes
Communicate to CSO and communities medical review status monthly
Complete education and training on all electronic systems associated with appeals and denials including but not limited to payor portals and FISS systems
Conduct and participate in medical records and the appeal and denial training
Manage medical record claims tracking and trending of ADRs, appeals and denials
Serve as contact for payors/contractors on behalf of communities and Touchstone
Serve as a liaison between medical review and CBO, communities, and therapy providers
Assist with additional medical review related projects as identified by other Fundamental Medical Review Department stakeholders
Assist with other Clinical Reimbursement projects as indicated
STANDARDS:
Position-Specific:
Develop and implement a process and procedure for the timely submission of ADRs and Appeals.
Monitor the trends of denials and communicate those trends to operations, communities and rehab monthly
Utilize established database for storing ADRs and tracking status
Communicate the status of the ADRs with CSO RDO, Administrators, BOM, rehab and CBO monthly.
Establish a teaching and training program to follow-up on denial trends and findings
QUALIFICATIONS:
A current and valid Texas RN/LVN nursing, PT, PTA, OTR, OTA or SLP license
Familiar with Reimbursement system of Medicare, Medicaid & Case Management
Skilled Nursing Facility Experience as an MDS Nurse
CMAC certification or completion within 30 day of hire (2 year renewal)
Knowledge of state and federal regulations, both clinical and financial as it relates to the RAI process and reimbursement systems
In-depth knowledge of the clinical software billing system and the MDS process.
Proficient in the use of computer systems (WORD, Excel, EHR system, etc.)
Benefits:
We offer eligible team members an attractive benefit package that includes medical, dental, wellbeing, and vision benefits, along with other unique benefits including:
- Health Savings Allowance option for certain medical plans
- Paid Time Off; Bereavement Pay and Jury Duty Pay
- Tuition Grant Program
- Employee Referral Program
- Shine Bright Team Member Incentive Bonus Program
- Matching 401(k) matching
- OnShift Wallet- access to your earned money before payday
- Life and Supplemental Insurance
- UnitedHealth Group Rally rewards program
- Mileage reimbursement (designated Regional team members)
- Cell phone allowance (designated Regional team members)
- Company Car (designated Regional team members)
- Equity Plan for designated team members
- Legal benefits and will preparation
- Team Chaplain availability
EOE STATEMENT
We are an equal employment opportunity employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, disability status, protected veteran status or any other characteristic protected by law.
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