Regional Director of Clinical Reimbursement

Job Description: Regional Director of Clinical Reimbursement

Reports To: Regional Director of Operations
Location: Multi-Facility (Regional Travel Required)

Position Summary

The Regional Director of Clinical Reimbursement is responsible for leading and supporting facility-level reimbursement operations across an assigned regional portfolio of skilled nursing facilities. This position provides strategic oversight, education, and analysis to ensure clinical, financial, and regulatory excellence in all aspects of the PDPM reimbursement process, Case Mix Index (CMI) optimization, Quality Measures (QMs), and RAI/MDS compliance.

This role serves as the clinical reimbursement expert for the region, bridging clinical practice and financial performance through documentation integrity, proactive audit processes, and interdisciplinary collaboration.

Key Responsibilities

1. CMI & PDPM Optimization

• Analyze and monitor Case Mix Index (CMI) and PDPM components to ensure accuracy and maximize reimbursement potential.
• Conduct facility reviews to validate MDS coding accuracy and identify opportunities for optimization within the Nursing, PT/OT, SLP, and NTA components.
• Develop and/or maintain facility-specific CMI and PDPM tracking tools to measure performance against targets.
• Provide education and feedback to MDS Coordinators and IDT members on PDPM coding practices, documentation capture, and RAI accuracy.

2. ADRs, Audits, and Documentation Integrity

• Oversee timely and accurate submission of Additional Documentation Requests (ADRs), redeterminations, and appeals.
• Audit clinical records to ensure MDS and billing documentation support skilled level of care and PDPM coding.
• Track adjustment and denial trends; implement proactive strategies to reduce risk and improve claim acceptance rates.
• Serve as the regional contact for all audit and appeal activity, maintaining detailed tracking and outcome reporting.
• Participate in field operations audits to ensure reimbursement compliance and validate documentation accuracy.
• Provide regional oversight and guidance for the Utilization Management Review (UMR) process in Pennsylvania, ensuring timely submission, accurate documentation, and compliance with requirements.

3. Reimbursement Process Oversight

• Lead and standardize Triple Check and Utilization Review (UR) processes across the region.
• Monitor skilled certification/recertification compliance and ensure all documentation supports continued skilled services.
• Collaborate with operations, clinical, and business office leaders to align reimbursement with quality care delivery.
• Stay updated on CMS RAI Manual updates, state-specific reimbursement changes, and industry best practices; communicate and educate accordingly.
• Review and analyze reimbursement data to identify trends, variances, and opportunities for process improvement.

4. Quality Measures (QMs)

• Analyze Quality Measures, Five-Star ratings, and clinical outcomes to identify opportunities that impact reimbursement and quality performance.
• Partner with facility leadership to develop and implement improvement plans targeting key QM indicators such as falls, pain, ADL decline, and antipsychotic use.
• Monitor progress through data analysis, education, and ongoing performance review.

5. RAI Process Compliance

• Ensure adherence to RAI process requirements, including timely and accurate completion of MDS assessments and Care Area Assessments (CAAs).
• Conduct field-based RAI audits to confirm documentation consistency with assessment data.
• Provide ongoing guidance and education to MDS Coordinators to maintain compliance and improve workflow efficiency.
• Collaborate with facility and regional teams to address findings from audits and implement corrective action plans.

7. Training, Education, and Support

• Serve as the subject matter expert in PDPM, CMI, RAI, and reimbursement practices.
• Provide training and mentoring to facility MDS staff and IDT members on documentation, coding accuracy, and regulatory updates.
• Facilitate reimbursement calls and/or onsite education focused on PDPM, documentation standards, QMs, and compliance.
• Support onboarding and continuing education for new MDS and reimbursement team members across the region.

8.Other Duties as Assigned

• Performs other duties and special projects as assigned to support clinical, financial, and operational performance within the reimbursement department and ensure ongoing compliance with company and regulatory standards.

Qualifications

• Graduate of an accredited nursing program (ADN, BSN, or LPN).
• Advanced coursework in Clinical Reimbursement, Healthcare Administration, or Data Analytics preferred.
• RAC-CT certification strongly preferred.
• In-depth understanding of PDPM, CMI methodology, Medicare/Medicaid reimbursement, RAI process, and QM reporting.
• Strong analytical and communication skills with the ability to interpret clinical and financial data effectively.
• Proficiency with EHR systems (PointClickCare preferred), SimpleLTC, and Microsoft Excel.