What You'll Do:The
Director of Reimbursement provides strategic leadership and operational oversight for all revenue cycle, third-party billing, and capitation payment processes specific to the Program of All-Inclusive Care for the Elderly (PACE). This role is responsible for maximizing financial performance, ensuring accurate Medicare and Medicaid capitation rate setting and reconciliation, managing risk adjustment data (RAPS/EDPS), and maintaining strict compliance with federal and state regulatory frameworks. The ideal candidate possesses deep expertise in integrated care financing, capitated payment models, and financial reporting within geriatric or managed care environments.
Key Responsibilities- Capitation & Revenue Management:
- Oversee the end-to-end processing, reconciliation, and auditing of monthly Medicare and Medicaid capitation payments for PACE participants.
- Monitor and analyze membership/census data, retroactive adjustments, and state-specific Medicaid rate methodologies to ensure optimal revenue realization.
- Risk Adjustment & Data Submission:
- Direct the organization's risk adjustment data submission processes (EDPS/RAPS) to ensure complete, accurate, and timely capture of participant diagnostic data.
- Implement internal audits and clinical documentation improvement (CDI) initiatives to support compliant risk-adjustment scores that accurately reflect the acuity of the PACE population.
- Financial Reporting & Analysis:
- Partner with the finance and accounting teams to prepare accurate monthly revenue forecasts, variance analyses, and budgetary reports related to PACE reimbursement.
- Lead financial modeling for program expansions, new center openings, or changes in state/federal reimbursement policies.
- Regulatory Compliance & Auditing:
- Ensure full compliance with Centers for Medicare & Medicaid Services (CMS) and State Administering Agency (SAA) guidelines, regulations, and reporting requirements.
- Serve as the financial and reimbursement lead during external audits, state desk reviews, and CMS financial/compliance inspections. [
- Cross-Functional Leadership & Contracting:
- Collaborate with Clinical, Interdisciplinary Teams (IDT), and Health Information Management (HIM) to align documentation practices with revenue and compliance goals.
- Assist in negotiating financial terms for external provider network contracts, specialized services, and institutional care, ensuring alignment with PACE capitation constraints.
Required Skills/Abilities:- Technical Competencies:
- Expert understanding of CMS regulations, risk adjustment (HCC coding), and Medicaid rate-setting mechanisms.
- Advanced proficiency in financial modeling, data analytics, and Electronic Health Record (EHR) / billing systems.
- Soft Skills:
- Exceptional communication and executive presence, with the ability to translate complex reimbursement data for non-financial clinical and operational leaders.
- Strong project management skills with a meticulous eye for compliance and detail-oriented problem solving.
Perks!- Medical, Dental, Vision
- FSA, HSA
- Indemnity Plans
- 401k Matching
- Company Paid Life Insurance
- Company Paid STD & LTD
- Wellness Program Incentives
- Employee Referral Bonus
- EAP
- Teladoc and sooo much more!
What You'll Bring:- Education:
- Bachelor's degree in Finance, Accounting, Healthcare Administration, or a related field.
- Master's degree (MBA, MHA, or MPA) or CPA/CHFP certification preferred.]
- Experience:
- Minimum of 7+ years of progressive financial or revenue cycle management experience within healthcare, with at least 3-5 years focused on managed care, Medicare/Medicaid reimbursement, or capitated health plans.
- Direct working knowledge of the PACE model or integrated long-term care programs for older adults is strongly preferred.
