Clinical Director of Reimbursement

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