Director of Clinical Reimbursement - MDS/PDPMRemote | Massachusetts or VermontWe are seeking an experienced
Director of Clinical Reimbursement - MDS/PDPM to provide leadership and oversight across multiple skilled nursing facilities in Massachusetts and Vermont.
Position SummaryThe Director of Clinical Reimbursement - MDS/PDPM is responsible for overseeing
clinical reimbursement, MDS, PDPM, case-mix management, and Medicare/Medicaid compliance across a multi-site skilled nursing portfolio.
This position ensures accurate clinical documentation and coding, appropriate reimbursement, timely assessments, regulatory compliance, and successful audit outcomes.
The Director works closely with
MDS Coordinators, Directors of Rehabilitation, clinical leadership, respiratory teams, facility administrators, and finance leadership to monitor reimbursement performance, strengthen documentation practices, identify compliance risks, and support regulatory and survey readiness.
This role will also lead
ADR, TPE, and RAC audit responses, oversee CMI and PDPM processes, support MDS staffing and education, and coordinate reimbursement-related operations across facilities.
Key ResponsibilitiesMDS, PDPM & Clinical Reimbursement- Oversee MDS accuracy, PDPM compliance, CMI trends, and case-mix capture across facilities.
- Lead weekly PDPM and CMI review processes, including audit alerts, IPA reviews, and ARD scheduling.
- Review Section GG, active diagnoses, behavioral/SUD add-ons, and other MDS coding elements for accuracy.
- Oversee Medicare Part A appeals, beneficiary notices, at-risk cases, and coverage reviews.
- Review LCD and Medicare coverage criteria to support appropriate continued Medicare Part A stays.
- Maintain PDPM, CMI, and reimbursement tracking tools.
- Identify reimbursement trends, risks, and opportunities for improvement.
Audit & Regulatory Compliance- Lead ADR, TPE, and RAC audit responses from record retrieval through submission.
- Coordinate documentation and record requests with facilities, vendors, and external contractors.
- Maintain audit tracking logs and daily chart recaps.
- Oversee QRP validation audits, QIES reporting, and quality compliance reviews.
- Support mock surveys, infection control rounds, and overall survey readiness.
Rehabilitation Operations- Lead weekly QRM meetings and monthly DOR calls.
- Monitor rehabilitation statistics, utilization, budgets, GG scores, therapy triple-checks, and Part B billing.
- Partner with recruiting regarding rehabilitation staffing needs and onboarding.
- Support DOR onboarding, contractor interviews, and documentation compliance.
- Monitor therapy authorization and appointment processes.
Respiratory Program Oversight- Oversee respiratory documentation, billing, CPT/coding compliance, and ARD coordination.
- Monitor trach/vent census and validate UB billing against supporting documentation.
- Lead recurring compliance meetings with respiratory teams.
- Coordinate MDS and respiratory workflows to support accurate documentation and reimbursement.
Medicaid & Financial Operations- Oversee MassHealth enrollment, MDS audits, and MMIS billing reconciliation.
- Review scrubber reports and payor setup within PCC.
- Participate in financial and ACO review meetings.
- Monitor reimbursement trends and support accurate financial reporting.
Systems & Facility Implementation- Lead onboarding of new facilities, including PCC setup, assessments, workflows, and staff education.
- Establish standardized reimbursement and documentation processes across facilities.
- Partner with clinical, operational, finance, rehabilitation, respiratory, and MDS leadership on performance improvement initiatives.
Qualifications- Bachelor's degree in Nursing, Healthcare Administration, Health Information Management, or a related field preferred.
- Significant experience in skilled nursing reimbursement, MDS, PDPM, and Medicare/Medicaid processes.
- Strong knowledge of MDS 3.0, PDPM, CMI, Medicare Part A, Medicaid, and reimbursement regulations.
- Experience managing ADR, TPE, RAC, or other Medicare audits.
- Experience overseeing MDS and reimbursement operations across multiple skilled nursing facilities preferred.
- Strong understanding of Section GG, clinical documentation, coding accuracy, and triple-check processes.
- Experience with PointClickCare (PCC) preferred.
- Strong analytical, organizational, communication, and leadership skills.
- Ability to work independently in a fully remote environment while collaborating effectively with facility and corporate teams.
- Must be located in Massachusetts or Vermont.
Benefits- Competitive Salary
- Weekly Pay
- Medical, Dental, and Vision Insurance
- Short- and Long-Term Disability Insurance
- Paid Time Off (PTO) for Full-Time Employees
- 401(k)
- Paid Holidays
- Professional Education and Development Opportunities
- Supportive Leadership Team
- Remote Work Environment
