Clinical Reimbursement Specialist

Clinical Reimbursement Specialist RN/LPN

Location

Saint Cloud, FL

Department

Nursing

FLSA Status

Non-Exempt

Reports To

DON

Shifts Hiring

Full-time

Additional Information

Sign on Bonus $2500.00

Pay Grade

90K to 100K

The Clinical Reimbursement Specialist is an on-site facility resource responsible for coordinating and monitoring the Minimum Data Set (MDS), resident assessment, care-planning, skilled coverage, and reimbursement processes. The position works directly with the Administrator, Director of Nursing, MDS team, therapy, Business Office, medical providers, and interdisciplinary team to ensure that resident assessments are accurate, timely, clinically supported, and compliant with Medicare, Medicaid, managed care, the Patient-Driven Payment Model (PDPM), and applicable federal and state requirements.

The specialist maintains daily visibility into facility admissions, payer changes, clinical changes, assessment schedules, documentation quality, authorization requirements, and reimbursement risks. The role supports appropriate reimbursement only when it is fully supported by the resident’s condition, services provided, and the medical record.

• Maintain the facility MDS assessment calendar and monitor all assessment reference dates, completion dates, transmission deadlines, and required corrections.
• Coordinate comprehensive, quarterly, significant-change, significant-correction, entry, discharge, and Medicare assessments in accordance with the RAI Manual and CMS requirements.
• Review MDS coding for consistency with the resident’s current condition, diagnoses, functional status, clinical services, therapy services, restorative programs, and supporting documentation.
• Monitor Care Area Assessments, care-plan development, and interdisciplinary participation to ensure identified needs are addressed and documentation is complete.
• Track rejected submissions, validation reports, warning messages, late assessments, modifications, and inactivations through resolution.
• Provide coverage or direct assistance with MDS completion when operationally necessary and within the employee’s licensure and competency.

• Review Medicare Part A, Medicare Advantage, Medicaid, managed care, and other payer-related clinical documentation and reimbursement requirements.
• Validate PDPM components, including diagnoses, nursing classification, functional scoring, non-therapy ancillary services, speech-language pathology factors, and therapy utilization, as applicable.
• Monitor admissions, hospital returns, changes in condition, payer changes, interrupted stays, and other events that may affect assessment or reimbursement requirements.
• Identify potential missed reimbursement, unsupported coding, documentation inconsistencies, or compliance risks and promptly communicate findings to facility leadership.
• Participate in Triple Check and other pre-billing reviews to validate census, covered days, payer source, assessment completion, physician certification, authorization, and supporting documentation.
• Collaborate with the Business Office and managed care personnel to monitor authorizations, continued-stay reviews, notices, denials, and appeal deadlines.

• Conduct routine concurrent and retrospective medical record audits to verify that documentation supports skilled coverage, medical necessity, diagnoses, MDS coding, services rendered, and reimbursement.
• Review nursing documentation, physician and practitioner notes, hospital records, therapy documentation, medication and treatment records, restorative nursing records, care plans, and other supporting…