Clinical Director of Reimbursement

Job description

PIONEER HEALTHCARE MANAGEMENT
Job Description
Title: Director of Reimbursement
Reports to: Director of Operations
Effective Date: 10.14.2023 Review Date: 5.29.2025
Corporate Leadership
 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.
Regulatory Compliance
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.
MDS Oversight
Oversee:
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 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
Reimbursement Oversight
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
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 Diagnosis validation
 State reimbursement requirements
 Medicaid audits
Managed Care
 Authorization management
 Documentation review
 Clinical updates
 Denial prevention
 Appeals support
Clinical Documentation Improvement (CDI)
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
PDPM Oversight
Review and validate:
Nursing Component
 Extensive Services
 Special Care High
 Special Care Low
 Clinically Complex
 Behavioral Symptoms
 Reduced Physical Function
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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
MDS Coding Audits
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
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 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
Quality Measures Oversight
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
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 Decline in ADLs
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.
Education & Training
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.
Auditing Responsibilities
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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.
Operational Support
Assist facilities with:
 Survey preparation
 Mock surveys
 Focused MDS reviews
 Revenue recovery initiatives
 New facility acquisitions
 Facility transitions
 Interim MDS coverage
 Regulatory compliance initiatives
Reporting Responsibilities
Prepare and present monthly corporate reports including:
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 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