Clinical Director of Reimbursement
Listed on 2026-09-12
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Healthcare
Healthcare Management, Healthcare Compliance
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Clinical Director of ReimbursementFull Time Bingham Farms, MI, US
PIONEER HEALTHCARE MANAGEMENT
Job Description
Title:
Director of Reimbursement
Reports to:
Director of Operations
Effective Date: 10.14.2023 Review Date: 5.29.2025
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
Anti-psychotic 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:
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