Clinical Director of Reimbursement

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Full 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.

• 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.

• ARD management
• Assessment completion
• MDS accuracy
• Timely transmission
• Validation reports
• Assessment modifications
• Error corrections

• Entry Tracking
• OBRA Assessments
• PPS Assessments
• IPA Assessments
• Significant Change Assessments
• Quarterly Assessments
• Annual Assessments

• Provide oversight of:
• PDPM classification
• Skilled documentation
• Triple Check process
• Notice of Medicare Non-Coverage (NOMNC)
• Denial prevention
• Appeals support

• Case Mix accuracy
• Diagnosis validation

• Authorization management
• Documentation review
• Clinical updates
• Denial prevention
• Appeals support

• 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

• Review and validate:
• Extensive Services
• Special Care High
• Special Care Low
• Clinically Complex
• Behavioral Symptoms
• Reduced Physical Function

• Physical Therapy
• Occupational Therapy
• Speech Therapy

• IV medications
• Respiratory therapy
• Dialysis
• Wounds
• Isolation
• High-cost services

• 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

• Review documentation from:
• Nursing
• Therapy
• Respiratory
• Social Services
• Activities
• Pharmacy
• Skilled services
• MDS coding
• Reimbursement
• Quality Measures

• 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.

• 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.

• 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.

• Conduct routine corporate audits of:
• MDS completion
• MDS accuracy
• Medicaid case mix
• Managed Care
• Triple Check
• Care Plans
• CAAs
• Skilled documentation
• Diagnosis coding
• Section GG
• Section K
• Therapy documentation
• PDPM optimization
• Issue written reports with corrective actions and follow-up plans.

• Assist facilities with:
• Survey preparation
• Focused MDS reviews
• Revenue recovery initiatives
• New facility acquisitions
• Facility transitions
• Interim MDS coverage
• Regulatory compliance initiatives

Prepare and present monthly corporate reports including: