Senior Clinical Reimbursement Consultant; RN

At Limitlessli, we specialize in recruiting, hiring, and managing high-caliber remote staff for dynamic and growing healthcare facilities. Leveraging our extensive global network, we connect clients with highly qualified professionals, offering tailored services to meet our clients' unique business needs.

The Senior Clinical Reimbursement Consultant (RN) is a highly skilled clinical reimbursement expert responsible for optimizing Medicare Part A PDPM reimbursement, Pennsylvania Medicaid Case Mix (CMI), MDS coding accuracy, clinical documentation, regulatory compliance, and financial performance across multiple skilled nursing facilities.

Serving as a trusted advisor to executive leadership and interdisciplinary teams, this position combines advanced clinical expertise with strategic consulting to identify reimbursement opportunities, remove operational barriers, improve documentation practices, and implement sustainable performance improvement initiatives.

The Senior Clinical Reimbursement Consultant partners with facility leadership to evaluate reimbursement processes, conduct on-site resident observations, validate MDS coding accuracy, identify clinical and operational opportunities, educate interdisciplinary teams, and implement innovative solutions that improve reimbursement integrity while supporting exceptional resident care.

This position requires independent decision-making, executive-level communication skills, strong clinical judgment, and the ability to influence organizational performance through collaboration, education, and strategic leadership.

Strategic Reimbursement Consulting

• Serve as the clinical reimbursement consultant for assigned skilled nursing facilities.
• Provide strategic guidance to executive leadership regarding Medicare PDPM reimbursement, Pennsylvania Medicaid Case Mix (CMI), clinical documentation improvement, and reimbursement optimization.
• Identify operational, clinical, documentation, and workflow barriers that negatively impact reimbursement and financial performance.
• Perform root cause analyses to determine the underlying causes of reimbursement challenges and operational inefficiencies.
• Develop innovative, practical, and sustainable solutions that improve reimbursement outcomes while enhancing clinical quality and operational efficiency.
• Lead interdisciplinary problem-solving initiatives and facilitate implementation of corrective action plans.
• Translate complex reimbursement regulations into actionable strategies that improve organizational performance.
• Monitor implementation of recommendations and evaluate measurable outcomes.

Resident Observation & Clinical Validation

• Conduct on-site resident observations and focus clinical assessments to validate MDS coding accuracy and supporting documentation.
• Observe resident performance during routine care and therapy to validate coding for:
  • Section GG
  • Activities of Daily Living (ADLs)
  • Mobility and transfers
  • Self-care
  • Cognition
  • Mood and behaviors
  • Communication
  • Swallowing disorders
  • Skin integrity
  • Restorative nursing
  • Respiratory services
  • Skilled nursing services
  • Special treatments and procedures
• Compare resident observations with nursing, therapy, physician, and MDS documentation to identify discrepancies.
• Validate that documentation accurately reflects resident acuity, clinical complexity, skilled services, and resource utilization.
• Identify documentation deficiencies affecting reimbursement, Quality Measures, and regulatory compliance.
• Provide immediate education and coaching based on resident observation findings.
• Utilize advanced clinical assessment skills to support reimbursement integrity and regulatory compliance.

Medicare Part A PDPM Reimbursement

• Conduct comprehensive Medicare Part A PDPM reimbursement reviews.
• Validate ICD-10-CM coding and clinical category assignment.
• Review PT, OT, SLP, Nursing, and NTA classifications for reimbursement accuracy.
• Identify opportunities for Interim Payment Assessments (IPAs).
• Evaluate assessment timing and Interrupted Stay policy compliance.
• Validate Section GG coding through chart review and resident observation.
• Review physician documentation supporting primary diagnoses and skilled services.
• Identify reimbursement opportunities before claim submission.
• Collaborate with interdisciplinary teams to maximize reimbursement while maintaining regulatory compliance.

Pennsylvania Medicaid Case Mix (CMI)

• Monitor Case Mix Index performance across assigned facilities.
• Audit MDS coding affects Pennsylvania Medicaid…