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Job Summary
The IRF-PAI Compliance Coordinator, RN oversees the Prospective Payment System process in an Inpatient Rehab setting, ensuring accurate IRF-PAI completion, compliance with Medicare rules, and proper reimbursement. This role is responsible for reviewing admissions for eligibility, monitoring documentation, coordinating team conferences, educating staff, managing denials, and tracking key data to support quality care and financial integrity. Maintains efficient and exacting system for PPS assessment and implementation. Evaluates that the plan of care for patients is effective and that Functional Measure changes, LOS and IRF-PAI efficiencies are reflective of regional outcomes. Responsible for collection of statistical information related to CARF/CMS accreditation requirements. Communicates admission criteria and insurance coverage details to ARU Physicians and Clinical Liaisons per CMS guidelines. Reports to the Manager/Director/CNO to ensure goal attainment.
Responsibilities
- Participates in formatting, interpreting and implementing department objectives of providing quality patient care in compliance with established guidelines and regulations.
- Executes and evaluates effectiveness of patient care plans, PPS-IRF completion and transmission and JCAHO regulations and department and facility administrative policies and procedures assuring that the delivery and documentation of care is reflected in the medical record.
- Attends department meetings, communicates changes in policies and procedures and discusses department concerns/priorities with co-workers.
- Coordinates with physicians and ancillary departments the assessment of patient needs and treatments and updates billing information.
- Evaluates each patient upon admission to determine medical necessity for Inpatient Rehab and ensures completion of IRF-PAI assessments in compliance with federal and state regulations.
- Audits patient records to ensure documentation aligns with IRF-PAI/Care Plan processes and complies with the 60% rule, 3-hour rule, and other regulatory requirements.
- Maintains professional competence through participation in both mandatory and voluntary Inservice programs and continuing education programs.
- Develops and maintains a positive work climate and the overall team effort of the hospital.
- Responsible for team conference with families ensuring all conversations and decisions are accurately documented to ensure facilities processes are following CMS regulations.
- Monitors and interprets updates to CARF and CMS regulations to ensure documentation and reporting meet accreditation standards and support ongoing compliance.
- Collaborates with Corporate to resolve payor communication issues, reduce denials, and apply lessons learned to enhance future reimbursement outcomes.
- Completes assigned goals.
Specifications
Experience
- Two (2) years Clinical Experience. Knowledge of JCAHO requirements for determining patient level of care and planning.
Minimum Required
- Two (2) years Clinical Experience. Knowledge of JCAHO requirements for determining patient level of care and planning.
Preferred/Desired
- Rehab experience preferable
Education
- Registered Nurse or Masters. Degree in a related health care field.
Minimum Required
- Registered Nurse or Masters. Degree in a related health care field.
Preferred/Desired
Training
Minimum Required
Preferred/Desired
Special Skills
- Excellent communication skills. Advanced computer literacy skills.
Minimum Required
- Excellent communication skills. Advanced computer literacy skills.
Preferred/Desired
Licensure
Minimum Required
Preferred/Desired
