Clinical Director of Reimbursement

Director Of Reimbursement

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

Medicare Part A regulations

Medicaid reimbursement regulations

Patient Driven Payment Model (PDPM)

OBRA Requirements

State Survey Requirements

HIPAA

Corporate Compliance Program

Monitor compliance through routine auditing and reporting.

Oversee:

Assessment scheduling

ARD management

Assessment completion

MDS accuracy

Timely transmission

Validation reports

Assessment modifications

Inactivation requests

Error corrections

Monitor:

Entry Tracking

OBRA Assessments

PPS Assessments

IPA Assessments

Significant Change Assessments

Quarterly Assessments

Annual Assessments

Discharge Assessments

Provide oversight of:

Medicare Part A

PDPM classification

Skilled documentation

Triple Check process

Medicare eligibility

Benefit day management

Notice of Medicare Non-Coverage (NOMNC)

Denial prevention

Appeals support

Medicaid

Case Mix accuracy

Diagnosis validation

State reimbursement requirements

Medicaid audits

Managed Care

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:

PDPM reimbursement

Medical necessity

Skilled services

Diagnosis coding

Functional status

Clinical complexity

Review and validate:

Nursing Component

Extensive Services

Special Care High

Special Care Low

Clinically Complex

Behavioral Symptoms

Reduced Physical Function

Therapy Components

Physical Therapy

Occupational Therapy

Speech Therapy

NTA Component

Review supporting documentation for:

IV medications

Respiratory therapy

Dialysis

Wounds

Isolation

Comorbidities

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

Clinical Documentation Audits

Review documentation from:

Nursing

Physicians

Nurse Practitioners

Therapy

Respiratory

Dietary

Social Services

Activities

Pharmacy

Ensure documentation supports:

Skilled services

MDS coding

Reimbursement

Care planning

Quality Measures

Monitor corporate Quality Measures, including:

Hospital Readmissions

Falls with Major Injury

Pressure Injuries

Weight Loss

Antipsychotic Use

Catheter Utilization

Urinary Tract Infections

Vaccinations

Functional Improvement

Develop action plans for facilities not meeting benchmarks.

Five-Star Quality Rating

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

Medicare regulations

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

ARD scheduling

Medicare documentation

Medicaid case mix

Managed Care

Triple Check

Care Plans

CAAs

Skilled documentation

Diagnosis coding

Section GG

Section K

Therapy documentation

Physician documentation

PDPM optimization

Issue written reports with corrective actions and follow-up plans.

Assist facilities with:

Survey preparation

Mock surveys

Focused MDS reviews

Revenue recovery initiatives

New facility acquisitions

Facility transitions

Interim MDS coverage

Regulatory compliance initiatives

Prepare and present monthly corporate reports including:

MDS completion compliance

Transmission compliance

PDPM reimbursement trends

Medicare census

Medicaid Case Mix

Managed Care census

Five-Star trends

Quality Measures

Triple Check compliance

Revenue opportunities

Audit findings

Facility scorecards

Pioneer Health Care Management, Inc.