Skilled Nursing Facility (SNF) / Patient-Driven Payment Model (PDPM)

Responsibilities
Quality Review and Audit Oversight: Demonstrates expertise in the following:

Perform quality reviews of completed SNF/PDPM audits to validate coding accuracy, reimbursement determinations, supporting documentation, and audit rationale

Ensure audit findings align with CMS guidelines, RAI Manual requirements, PDPM regulations, client requirements, and departmental procedures

Document quality review findings clearly and accurately

Identify quality trends, recurring audit errors, and opportunities for process improvement

Provide constructive written feedback to auditors

Performance Management: Consistently contributes to client saving/internal revenue goals

Achieves productivity and quality goals

Team Work: Understands duties, team goals, and consistently achieves performance required

Demonstrates awareness of goals by achieving performance requirements (self-accountability)

Responds timely to emails and meeting requests (is in attendance as scheduled/requested)

Actively participates in discussions and Team Meetings, providing suggestions of improvement or volunteers when needed

Adhere to all EXL Health policies and procedures

Report any problems in the audit or quality process to Quality Manager for resolution.

Identify and communicate facility and provider specific issues that impact audits.

Continuous Improvement / Education

Maintain current knowledge of CMS regulations, PDPM reimbursement methodology, MDS 3.0 requirements, and industry best practices

Monitor regulatory changes affecting SNF/PDPM auditing activities

Qualifications
Registered Nurse, Licensed Practical Nurse, or Licensed Vocational Nurse license in good standing in the state that you reside

Minimum of 5 years’ experience with SNF clinical, MDS 3.0 completion, PDPM reimbursement methodology, quality assurance, auditing, and/or related experience

Advanced knowledge of MDS 3.0 coding guidelines, skilled nursing facility (SNF) levels of care, and PDPM reimbursement

Previous experience/exposure to the billing of HIPPS codes

Experience reviewing audit findings, conducting quality revises, or performing compliance monitoring activities

Knowledge & Skills

Experience with: Excel, PowerPoint, Outlook, and Word

Experience with Encoder tools such as 3M

Experience with and expertise with Medicare Local Coverage Determinations (LCD) and National Coverage Determinations (NCD)

Must be detail oriented

Must have excellent verbal and written communication skills

Must be self-directed and able to work with minimum oversight