Clinical Director of Reimbursement

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Clinical Director of Reimbursement

Full Time Bingham Farms, MI, US

PIONEER HEALTHCARE MANAGEMENT

Job Description

Title: Director of Reimbursement

Reports to: Director of Operations

Effective Date: Review Date:

Provide leadership and oversight to all facility MDS Coordinators and Regional Clinical Teams.

Standardize MDS processes across all facilities.

Develop and implement corporate MDS policies and procedures.

Ensure consistency with CMS regulations and company standards.

Assist facilities during leadership transitions and vacancies.

Provide on-site support during surveys, focused reviews, and regulatory investigations.

Serve as the corporate expert for MDS, PDPM, and reimbursement.

Regulatory Compliance

Ensure all facilities maintain compliance with:

CMS Resident Assessment Instrument (RAI) Manual

Medicaid reimbursement regulations

OBRA Requirements

State Survey Requirements

HIPAA

Corporate Compliance Program

Monitor compliance through routine auditing and reporting.

MDS Oversight

Oversee:

ARD management

Assessment completion

MDS accuracy

Timely transmission

Validation reports

Assessment modifications

Error corrections

Monitor:

Entry Tracking

OBRA Assessments

PPS Assessments

IPA Assessments

Significant Change Assessments

Quarterly Assessments

Annual Assessments

Reimbursement Oversight

Provide oversight of:

PDPM classification

Skilled documentation

Triple Check process

Notice of Medicare Non-Coverage (NOMNC)

Denial prevention

Appeals support

Medicaid

Case Mix accuracy

Diagnosis validation

Managed Care

Authorization management

Documentation review

Clinical updates

Denial prevention

Appeals support

Clinical Documentation Improvement (CDI)

Collaborate with nursing leadership, therapy, physicians, dietary, and social services to ensure documentation

accurately supports:

Medical necessity

Skilled services

Diagnosis coding

Functional status

Clinical complexity

PDPM Oversight

Review and validate:

Extensive Services

Special Care High

Special Care Low

Clinically Complex

Behavioral Symptoms

Reduced Physical Function

Therapy Components

Physical Therapy

Occupational Therapy

Speech Therapy

Review supporting documentation for:

IV medications

Respiratory therapy

Dialysis

Wounds

Isolation

High-cost services

MDS Coding Audits

Audit:

Section A

Section B

Section C

Section D

Section E

Section F

Section G (if applicable)

Section GG

Section H

Section I

Section J

Section K

Section L

Section M

Section N

Section O

Section P

Section Q

Clinical Documentation Audits

Review documentation from:

Nursing

Therapy

Respiratory

Social Services

Activities

Pharmacy

Skilled services

MDS coding

Reimbursement

Quality Measures

Quality Measures Oversight

Monitor corporate Quality Measures, including:

Hospital Readmissions

Falls with Major Injury

Pressure Injuries

Antipsychotic Use

Urinary Tract Infections

Functional Improvement

Decline in ADLs

Develop action plans for facilities not meeting benchmarks.

Five-Star Quality Rating

Monitor and improve:

Quality Measures

Health Inspection outcomes

Staffing metrics

MDS accuracy affecting publicly reported measures

Collaborate with facility leadership to improve Five-Star performance.

Education & Training

Develop and provide education on:

CMS RAI Manual updates

PDPM

Section GG

Section K

Clinical documentation

ICD-10 coding

Medicaid updates

Managed Care requirements

Triple Check process

Quality Measures

Provide orientation for new MDS Coordinators and ongoing competency validation.

Auditing Responsibilities

Conduct routine corporate audits of:

MDS completion

MDS accuracy

Medicaid case mix

Managed Care

Triple Check

Care Plans

CAAs

Skilled documentation

Diagnosis coding

Therapy documentation

PDPM optimization

Issue written reports with corrective actions and follow-up plans.

Operational Support

Assist facilities with:

Survey preparation

Focused MDS reviews

Revenue recovery initiatives

New facility acquisitions

Facility transitions

Interim MDS coverage

Regulatory compliance initiatives

Reporting Responsibilities

Prepare and present monthly corporate reports including: