A Clinical Reimbursement Specialist is a qualified professional who collaborates with the healthcare staff and processes insurance reimbursements. Typical work activities carried out on daily basis is mentioned on the Clinical Reimbursement Specialist Resume as – making sure the customers receive accurate reimbursement for their claims, investigating claims issues, making recommendations to the health care unit’s management, updating patient files, reviewing insurance claims in the billing department, ensuring or making sure the customers receive accurate reimbursement for their claims, updating patient’s medical files, investigating claims issues and making recommendations to the management for process improvement.
Job applicants for this role must have solid verbal and written communication skills to audit, and craft reports, and to deal with troublesome accounts. They should think independently and be able to deal with customer inquiries and issues. They have to be well-versed with the company’s rules and regulations and deal with customers in a patient and professional way. While a degree is considered mandatory, having experience in medical terminology, insurance billing, or the collection and accounts receivable will make one stand out from competing applicants.
Headline : Clinical Reimbursement Specialist with years of managerial experience in skilled nursing facility, capable of delivering the following key objectives: Leading the daily operations of the nursing staff to achieve quality performance and continuous, efficient functioning through exceptional nursing services. Ensuring clients' comfort to the highest possible degree, while meeting highest level medical care.
Skills : Case Management, Supervisory, Training.
Description :
Responsible for all MDS (Minimum Data Set) assessments for 103 bed facility on quarterly basis.
Responsible for implementation of all care plans and conducting care plan meetings three times a week.
Responsible for multiple audits on quarterly basis.
Demonstrated ability to lead and motivate outstanding healthcare teams.
Ensured HIPAA compliance.
Provided patient education.
Provided behavioural/emotional support and supervision for those with dementia and Alzheimer's.
Experience
5-7 Years
Level
Executive
Education
ASN In Nursing
Clinical Reimbursement Specialist Resume
Headline : An experienced Clinical Reimbursement Specialist; with extensive functional experience of clinical reviews, case management and claims/ authorization process and management of call center activities. Experienced in call center daily operations, meeting contractual obligations, KPI's with continuous education and staff development.
Skills : Microsoft Office, Excel, Clinical Skills, Medicare.
Description :
Provided ongoing consulting support to twelve skilled nursing facilities in Wisconsin.
Conducted both onsite and internet based education and training using LMS, Go To Meeting and WebEx on a variety of topics including: RAI process, MDS completion, Medicare & Medicaid reimbursement guidelines, managed care and Medicare Advantage programs, nursing documentation to support Medicare coverage, and Medicare Denial Letters.
Analysed Medicare and Medicaid rates and identified strategies to increase rates where clinically appropriate.
Conducted weekly focus calls with DRAs/RNACs.
Analyzed Medicare and Medicaid rates and identified strategies to increase rates where clinically appropriate.
Acted as an MDS/Medicare resource to the State Director of Clinical Services & Clinical Support Consultants.
Supported Regional Director of Operations, Executive Directors and Director of Nursing on a variety of issues including: rates, compliance, RNAC assessment & RNAC recruiting.
Experience
5-7 Years
Level
Executive
Education
BS In Education
Clinical Reimbursement Specialist Resume
Objective : To gain a position as a Clinical Reimbursement Specialist with your organisation and become a successful member of your team, an experienced RN with a rounded variety of experience. I am especially adept in communication, both verbal and written, and possess excellent management and organisational skills.
Skills : Proficient In Microsoft Office, Medicare And Medicaid Reimbursement Experience;.
Description :
Reported directly to the Administrator and my responsibilities included collaboratively coordinating, and overseeing the interdisciplinary assessments and the care planning process for a 120 bed skilled nursing facility.
Retrieved and entered the necessary clinical data and prepared and managed the Minimum Data Set (MDS), Raps/CAA, and Care Plans, per Medicare and Medicaid guidelines for the purposes of quality improvement and to safeguard a deficiency free survey; also ensured that the organization would have the appropriate case mix reimbursement.
Conducted interviews and facilitated open communication between the patients, family members, and the nursing staff in order to guarantee the accuracy of the assessment.
Led the interdisciplinary care plan team meetings and added and updated the necessary changes as it applied to the care plan process.
Educated and in-serviced nurses and nursing assistants on charting and care plans to make sure that the care of the patients was implemented accordingly.
Participated in the pre-admission and the discharge planning process, and evaluated the appropriateness of referrals together with the Rehab and Social Services departments.
Rotated as the on call nurse manager to address scheduling issues and call outs by the nursing staff.
Experience
2-5 Years
Level
Junior
Education
Bachelor In General Studies
Clinical Reimbursement Specialist Resume
Objective : Clinical Reimbursement Specialist is responsible for Providing administrative support to medical providers and health plans, Ensuring that all necessary documentation is received in a timely manner, Maintaining the services of one or more full time clinical staff who provides support to any provider at all times; this includes but is not limited to physicians, nurses, assistants and other clinical staff.
Skills : Excellent Organizational , Attention To Detail,.
Description :
Responsible for the management and oversight of 6 facilities in Tennessee and Virginia.
Implemented and directed Medicare auditing and systems review of: admission prescribing and documentation requirements, financial documentation requirements, clinical documentation, strategic selection of assessment reference dates, MDS accuracy, ADL score tracking, denial management, RUG management, and therapy implementation and documentation.
Provided interdisciplinary team training of MDS and PPS, documentation requirements, RUG groups, admission strategies, and role and responsibility of the MDS coordinators.
Kept facilities informed of updates and regulation changes.
Performed financial analysis of: rate projections, monthly RUG distribution, and length of stay.
Performed clinical analysis to: monitor weekly utilization review meetings, correct MDS coding, nursing documentation, and distribution of RUG scores.
Reclaimed $20,000 in lost revenue during the first 90 days.
Experience
2-5 Years
Level
Executive
Education
MSN In Informatics
Clinical Reimbursement Specialist Resume
Objective : To obtain Full time employment in a progressive organization where my training and experience will be challenging and rewarding. Qualification Profile: Dedicated and patient-focused Registered Nurse with proven strengths in MDS, Restorative development, Home Health Care and family advocacy. Exceptional capacity to multi-task: manage numerous, often competing priorities with ease and foster the provision of superior patient care.
Skills : Patient Care, Planning, Educational Skills.
Description :
Oversaw MDS daily operations in accordance with Sate law.
Maximized reimbursement through chart reviews and MDS audits Daily meetings with Therapy director to discuss residents daily minutes.
Monitored and improved facilities 5 Star Report.
Monitored and improved facilites quality measures through educational interventions.
Trained and education with Current MDS nurse Oversee facilities Restorative program.
Responsible for following all OMRA and OBRA guidelines for timely and accurate MDS completion.
Created and maintained care plans.
Experience
2-5 Years
Level
Executive
Education
Bachelors
Clinical Reimbursement Specialist Resume
Summary : Clinical Reimbursement Specialist with nearly 20 years experience in skilled long term care and 12 years experience as MDS nurse and utilization review. Attributes Patient Advocate Excellent judgment Critical Thinker Proactive Resident and Family Educator Patient Centered Strong computer skills Adapts Easily.
Skills : Medicre, Clinical Program Management, Planning.
Description :
Worked closely with all members of the interdisciplinary team to ensure comprehensive care management.
Analyzed Medicare and Medicaid rates and identified strategies to increase rates where clinically appropriate.
Participates in the Manager on Duty coverage for the facility on a weekend rotation that includes visits to our patients at hospitals and marketing.
Provided DHS (Department of Health Services) with corrective action plans.
Participated in unit based Quality Assurance Program.
Provided information about clinical programs and their benefits to physicians, hospitals, and other payors in the United States.
Experience
10+ Years
Level
Senior
Education
Diploma
Clinical Reimbursement Specialist Resume
Objective : Clinical Reimbursement Specialist is responsible for Developing a complete understanding of the service provided by each facility; this includes but is not limited to billing codes, reimbursement rates and forms; this includes but is not limited to coordination of payments for services provided on behalf of health plans by various facilities, Developing an understanding of health plan reimbursement policies; this includes but is not limited to coverage levels, exclusions or limitations on services or drugs covered.
Skills : Debugging, Medical Skills, Reviewing.
Description :
Ensured compliance with all applicable laws by ensuring that programs are accurate and up to date with respect to clinical standards and guidelines.
Provided expert testimony at regulatory hearings on behalf of the insurance company or on behalf of the payor when required.
Participated in process improvement efforts with respect to reimbursement practices such as electronic medical records (EMR) technology, price negotiation techniques, provider cost analysis techniques, etc., that contribute toward reducing costs for providers and decreasing provider revenues for payors.
Worked closely with other members.
Developed a client relationship by partnering with various healthcare providers, insurance companies, and third party payers to provide reimbursement support services to the Medical Centers clients.
Developed a clients reimbursement policy from scratch or reviewing existing policies from different providers.
Developed new policy interpretations or modifications.
Experience
2-5 Years
Level
Executive
Education
GED
Clinical Reimbursement Specialist Resume
Summary : Clinical Reimbursement Specialist with 8 years of experience in Developing and managing a clinical workflow system with functionality to track patient information from multiple providers, Creating billable activities and associated billing rates for each provider, Providing technical support to providers and other healthcare professionals on the use of the system.
Responded to client inquiries; and submitted claims for payment.
Supported the Medical Centers clients by collecting relevant data in accordance with established guidelines.
Updated an individual clients policy and procedures on an ongoing basis through periodic reviews of clinical guidelines.
Identified and developed a clinical budget to support the needs of the department.
Ensured all procedures are covered under the Medical Center's policy and procedure manual in accordance with its financial resources.
Identified appropriate providers to provide services to patients in accordance with accepted billing standards (e.g., physician fee schedule).
Assessed, prioritized and billed for all services provided by a provider on a case/case basis as directed by departmental policy or procedure manual.
Experience
7-10 Years
Level
Management
Education
MS
Clinical Reimbursement Specialist Resume
Objective : Clinical Reimbursement Specialist is responsible for Identifying trends in provider reimbursement rates and work with management to develop a plan for future growth in revenue, Tracking patients using the system for billing purposes, gather data about patient care, and make recommendations for future changes in billing procedures or policies, Responding to telephones from physicians regarding payment issues via email or conference call, Consulting with management on other issues relating to health care costs or reimbursement issues.
Skills : Billing, Programming, Evaluation Skills.
Description :
Managed or coordinated physician referrals for patients in accordance with departmental policies or procedure manual.
Assisted physicians in the provision of services through coordination between providers and departments within the hospital.
Ensured that all documents required.
Provided clinical and financial support to customers in all phases of the payment process including pre-authorization, claim submission, review and approval. This includes working with the patients provider/physician(s) as well as third party payers such as Medicare, Medicaid and other government programs.
Identified and evaluated issues related to patient care, including specialties within the health care system; financial definitions and trends; cost containment strategies; payment policies; and provider reimbursement methods.
Communicated with providers about the results of the evaluation process. The evaluation may be used as a basis for a proposed change in rates or payment policies.
Interpreted data from the evaluation process in order to make recommendations about patient care options and cost containment strategies to physicians, payers, regulators, and other stakeholders within the health care system.
Experience
2-5 Years
Level
Executive
Education
MS
Clinical Reimbursement Specialist Resume
Objective : Clinical Reimbursement Specialist is responsible for Developing relationships with payors to review claims and negotiate reimbursement agreements, Representing the department in write and oral transaction negotiations with third parties (e.g., insurance companies), Developing and managing relationships with vendors; coordinating purchasing of supplies, and also Executing complex contract negotiations to obtain rebates from payors; coordinating receipts of goods/services from vendors; preparing invoices for invoicing purposes.
Skills : Clinical Skills, Risk Management, MS Office.
Description :
Developed a comprehensive reimbursement strategy.
Identified clinical service needs, manage clinical budgets, and ensure appropriate coverage.
Provided expert guidance to management on reimbursement issues and work with management to develop appropriate policies.
Negotiated with hospitals and physicians to obtain payment for medical services.
Advised hospital administrators on how to manage their facilitys financial performance.
Collected reimbursements from hospitals.
Ensured patient satisfaction by ensuring that patients are provided with quality care while minimising the risk of adverse event.
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