Director of Clinical Reimbursement

Regional Director of Clinical Reimbursement

Job Summary

We are seeking a highly skilled Regional Director of Clinical Reimbursement to oversee clinical reimbursement and case management services across multiple facilities. Reporting directly to the Director of Operations, this role will be responsible for ensuring compliance with Medicare A & B, Managed Care, Insurance, and Medicaid reimbursement processes while optimizing reimbursement strategies and accuracy.

Essential Qualifications

• Multi-facility/Regional Supervision experience required.
• 5 years of MDS experience in long-term care/skilled nursing.
• Active RN license required (RAC-CT preferred).
• 2 years of management experience with a strong leadership background.
• Extensive experience with Managed Care reimbursement processes and compliance.
  
  

Key Responsibilities

• Regulatory Compliance & Documentation
• Ensure organization-wide compliance with MDS, Quality Measures, Medicaid/Medicare RUGs, Medicaid Case Mix, and Medicare skilled care criteria.
• Perform periodic audits of MDS 3.0 documentation for accuracy and compliance.
• Conduct resident medical chart audits to ensure alignment between documented services and case-mix reimbursement categories.
• Validate Quality Measure reports for accurate MDS coding.
• Ensure adherence to RAI Manual and CMS regulations across all facilities.
• Managed Care Reimbursement Monitoring & Compliance
• Monitor and analyze Managed Care reimbursement trends, including case-mix implications and payer mix impact.
• Ensure compliance with contracted Managed Care payers and their reimbursement policies, including authorization and medical necessity documentation.
• Work closely with case management and business office teams to ensure accurate billing and claims submission for Managed Care residents.
• Provide oversight on Managed Care contract utilization and ensure facilities adhere to payer guidelines, timely filing requirements, and pre-authorization processes.
• Assist facilities in managing denied claims, appeals processes, and reimbursement disputes with Managed Care payers.
• Develop strategies for maximizing reimbursement under PDPM, Managed Care, and other payer models.
• Implement audit procedures to review Managed Care length of stay, therapy utilization, and skilled services documentation.
• Training & Support
• Train and support MDS Coordinators, Nursing, and Clinical Services staff on reimbursement policies, payer guidelines, and Managed Care documentation requirements.
• Assist nursing teams in improving MDS assessment skills through formal and informal training.
• Provide consultation and training on Medicare, Managed Care, and state case mix payment systems.
• Audits & Performance Monitoring
• Conduct audits in compliance with company and divisional standards to ensure accurate reimbursement documentation.
• Monitor facility schedules for timely and complete MDS data submission as per Federal and State requirements.
• Analyze reimbursement trends, identify deviations, and implement corrective action plans.
• Evaluate facility compliance with Managed Care payer agreements, including authorizations, concurrent reviews, and claims management.
• Collaboration & Communication
• Act as a liaison between facilities, finance, MDS, nursing, and medical records teams to ensure accurate reimbursement levels.
• Work closely with corporate teams, facility administrators, and state representatives regarding Medicaid case-mix processes and electronic submissions.
• Collaborate with Managed Care representatives, revenue cycle teams, and facility leadership to address reimbursement challenges and implement best practices.
• Participate in PPS Meetings, Triple Check Meetings, and other compliance-focused initiatives.
• Recruitment & Operational Support
• Assist in the recruitment and hiring of MDS/MMQ professionals.
• Provide ongoing operational support and guidance to facilities regarding denial management, appeals, and reimbursement strategies.
  
  

Qualifications & Skills

• Valid RN license required.
• Extensive knowledge of Medicare, Medicaid, PDPM, QM, and CMI reimbursement systems.
• Strong expertise in MDS processes, Managed Care reimbursement models, and regulatory compliance.
• Regional MDS experience highly preferred.
• Proficiency in analyzing reimbursement trends, auditing, and implementing performance improvements.
• Experience with Managed Care contract negotiations, billing, and claims management.
• Strong leadership and communication skills with the ability to train and mentor teams.
• Must be willing to travel between facilities as needed.
  
  

Why Join Us?

This is an exciting opportunity for a seasoned MDS and reimbursement professional to impact multiple facilities and optimize reimbursement outcomes while ensuring compliance. If you are a strategic leader with expertise in clinical reimbursement, Managed Care, and team development, we invite you to apply!