Prospective Payment System Coordinator - Clinical Specialist

MINIMUM QUALIFICATIONS:

EDUCATION, CERTIFICATION, AND/OR LICENSURE:

1. 1. ADN, Diploma, BSN or higher degree OR equivalent professional degree in Physical Therapy, Occupational Therapy, or Speech Language Pathology.

2. Current license in one of the following:

- Current Registered Nurse license issued by the state in which services will be provided or current multi-state Registered Nurse license through the enhanced Nurse Licensure Compact (eNLC), OR

- Physical Therapist License through West Virginia Board of Physical Therapists OR Physical Therapist Compact License, OR

- Occupational Therapist License through West Virginia Board of Occupational Therapy, OR

- Licensed Speech Language Pathologist License through the West Virginia Board of Speech-Language Pathology & Audiology,

3. Obtain BLS within 30 days of hire

EXPERIENCE:

1. Two (2) years clinical experience

PREFERRED QUALIFICATIONS:

EXPERIENCE

1. Experience with the Inpatient Rehabilitation Facility Patient Assessment Instrument (IRF PAI) and Uniform Data System (UDS).

CORE DUTIES AND RESPONSIBILITIES: The statements described here are intended to describe the general nature of work being performed by people assigned to this position. They are not intended to be constructed as an all-inclusive list of all responsibilities and duties. Other duties may be assigned.

1. Regulatory Stewardship & Submission Integrity

Process Ownership: Direct the end-to-end IRF-PAI workflow, serving as the final authority on the accuracy and clinical validity of all data transmitted to CMS.

Documentation Auditing: Conduct concurrent and retrospective audits of Preadmission Screens (PASE), HPI, and Individualized Plans of Care to ensure they meet the "Conditions of Participation" and support the medical necessity of 24-hour rehab nursing.

Clinical Coding Liaison: Collaborate with physicians, case managers, and HIM coders to validate etiologic diagnoses and co-morbidities, ensuring the assigned Case Mix Group (CMG) accurately reflects the patient's complexity.

Regulatory Watch: Serve as the facility's Subject Matter Expert (SME) on CMS and PPS regulations, proactively identifying changes in federal mandates that impact operations or reimbursement.

2. Clinical Competence & Educational Leadership

Educational Curriculum Development: Design and deliver ongoing training programs for nurses, therapists, and physicians focused on standardized Care Set coding (Section GG) and "Intensity of Service" documentation.

Competency Management: Manage the facility's credentialing process for GG section scoring, including the initial check-off for new hires and annual re-credentialing for all interdisciplinary staff.

Clinical Mentorship: Facilitate care conferences to model high-level documentation of interdisciplinary team discussions and ensure the "patient story" is consistent across all clinical records.

Resource Development: Create tools, cheat sheets, and documentation templates that simplify complex CMS requirements for bedside staff.

3. Quality Analytics & Performance Improvement

Strategic Data Analysis: Interpret monthly outcome reports and CMS compliance data to identify performance trends, potential risks, and opportunities for operational growth.

Quality Initiative Leadership: Partner with the Rehab Leadership Team to architect and execute Action Plans (PDSA cycles) that target improvements in length of stay, functional gain, and 60% rule compliance.

Outcome Reporting: Communicate complex data sets-including regional benchmarking and outcome measures-to stakeholders during program development and rehab operations meetings.

Policy Stewardship: Lead the development and modification of internal rehabilitation policies to ensure they align with the latest industry standards and quality benchmarks.

PHYSICAL REQUIREMENTS: The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

1. Office work which includes sitting for extended periods of time.

2. Must have reading and comprehension ability.

3. Visual acuity must be within normal range.

4. Must be able to communicate effectively.

5. Must have manual dexterity to operate keyboard, fax machines, telephones and other business equipment.

WORKING ENVIRONMENT: The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

1. Office work which includes sitting for extended periods of time.

2. Maintains confidential home office space

3. Required weekends and holidays as assigned

SKILLS & ABILILTIES:

1. Effective verbal and written communication skills.

2. Strong interpersonal skills.

3. Strong attention to detail.

4. Knowledge of medical terminology required.

5. Knowledge of third party payers required.

6. Ability to use tact and diplomacy in dealing with others.

7. Working knowledge of computers.

8. Excellent customer service and telephone etiquette

9. Working knowledge of the Medicare Prospective Payment System.

Additional Job Description:

Scheduled Weekly Hours:

Shift:

Exempt/Non-Exempt:

Company:

Cost Center:

Address:

Equal Opportunity Employer

West Virginia University Health System and its subsidiaries (collectively "WVUHS") is an equal opportunity employer and complies with all applicable federal, state, and local fair employment practices laws. WVUHS strictly prohibits and does not tolerate discrimination against employees, applicants, or any other covered persons because of race, color, religion, creed, national origin or ancestry, ethnicity, sex (including gender, pregnancy, sexual orientation, and gender identity), age, physical or mental disability, citizenship, past, current, or prospective service in the uniformed services, genetic information, or any other characteristic protected under applicable federal, state, or local law. All WVUHS employees, other workers, and representatives are prohibited from engaging in unlawful discrimination. This policy applies to all terms and conditions of employment, including, but not limited to, hiring, training, promotion, discipline, compensation, benefits, and termination of employment.