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