Director of Clinical Reimbursement - MDS/PDPM

Job Description

Job Description

Director of Clinical Reimbursement – MDS/PDPM

The Director of Clinical Reimbursement – MDS/PDPM oversees clinical reimbursement, MDS, PDPM, case-mix management, and Medicare/Medicaid compliance across a multi-site skilled nursing portfolio. This leader ensures accurate clinical documentation and coding, appropriate reimbursement, timely assessments, and successful audit outcomes.

The Director partners closely with MDS Coordinators, Directors of Rehabilitation, clinical leadership, respiratory teams, facility administrators, and finance to monitor reimbursement performance, strengthen documentation practices, identify compliance risks, and support regulatory and survey readiness.

This role also leads ADR, TPE, and RAC audit responses; oversees CMI and PDPM processes; supports MDS staffing and education; and coordinates reimbursement-related operations across facilities.

Core Responsibilities

MDS, PDPM & Reimbursement

• Oversee MDS accuracy, PDPM compliance, CMI trends, and case-mix capture across facilities.

• Lead weekly PDPM and CMI review processes, including audit alerts, IPA reviews, and ARD scheduling.

• Review Section GG, active diagnoses, behavioral/SUD add-ons, and other MDS coding elements for accuracy.

• Oversee Medicare Part A appeals, beneficiary notices, at-risk cases, and coverage reviews.

• Review LCD and Medicare coverage criteria to support appropriate continued stays.

• Maintain PDPM, CMI, and reimbursement tracking tools.

Audit & Compliance

• Lead ADR, TPE, and RAC audit responses from record retrieval through submission.

• Coordinate documentation and record requests with facilities, vendors, and external contractors.

• Maintain audit tracking logs and daily chart recaps.

• Oversee QRP validation audits, QIES reporting, and quality compliance reviews.

• Support mock surveys, infection control rounds, and overall survey readiness.

Rehabilitation Operations

• Lead weekly QRM meetings and monthly DOR calls.

• Monitor rehabilitation statistics, utilization, budgets, GG scores, therapy triple-checks, and Part B billing.

• Partner with recruiting on rehabilitation staffing needs and onboarding.

• Support DOR onboarding, contractor interviews, and documentation compliance.

• Monitor therapy authorization and appointment processes.

Respiratory Program

• Oversee respiratory documentation, billing, CPT/coding compliance, and ARD coordination.

• Monitor trach/vent census and validate UB billing against supporting documentation.

• Lead recurring compliance meetings with respiratory teams.

• Coordinate MDS and respiratory workflows to ensure accurate reimbursement and documentation.

Medicaid & Financial Operations

• Oversee MassHealth enrollment, MDS audits, and MMIS billing reconciliation.

• Review scrubber reports and payor setup within PCC.

• Participate in financial and ACO review meetings.

• Monitor reimbursement trends and identify opportunities to improve accuracy and compliance.

Systems & Facility Implementation

• Lead onboarding of new facilities, including PCC setup, assessments, workflows, and staff education.

• Establish standardized processes across facilities and ensure consistent reimbursement practices.

• Partner with clinical, operational, finance, rehabilitation, respiratory, and MDS leadership on ongoing performance improvement.

Benefit Package

• Competitive Wages + Shift Differentials

• Weekly Pay!

• 6 Paid Holidays

• Medical, Dental, and Vision Insurance

• Long- and Short-Term Disability Insurance

• Paid Time Off (PTO) for Full-Time Employees

• 401(k)

• On-Site Employee Education and a Supportive Work Environment

Join Stellar Health Group and help us advance quality care across our facilities!

Stellar Health Group is an Equal Opportunity Employer.

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