The Clinical Reimbursement Program Manager will lead the development and implementation of clinical reimbursement programs to ensure compliance and optimized processes across skilled nursing facilities in Michigan and Ohio. This strategic role partners with leadership to enhance reimbursement accuracy and regulatory compliance while providing essential training and support to staff.
Key Responsibilities
Design and implement clinical reimbursement programs to support accurate RAI/MDS assessments and PDPM accuracy
Develop and maintain compliance tools, audit processes, and documentation standards related to reimbursement
Conduct root cause analyses of reimbursement trends, denials, and documentation deficiencies; recommend corrective actions
Provide ongoing education, training, and competency validation to Clinical Reimbursement Specialists, MDS Coordinators, IDT members, and nursing staff
Monitor regulatory changes affecting Medicare, Medicaid, and other payor sources; update internal processes and tools accordingly
Collaborate with clinical and operational leadership to align reimbursement strategies with resident care goals and quality outcomes
Support pre- and post-acute reimbursement audits and assist in developing response plans for external reviews
Participate in QAPI initiatives and provide data to support performance improvement
Assist in onboarding new clinical reimbursement staff and serve as a subject matter expert
Required Qualifications
Licensed Registered Nurse (RN) with current, active license in good standing
Minimum of 3 years of experience in clinical reimbursement, MDS, or case mix management in a skilled nursing facility
In-depth knowledge of PDPM, MDS 3.0, Medicare/Medicaid regulations, SNF PPS reimbursement systems, and regulatory requirements
Preferred Qualifications
RAC-CT certification
Demonstrated experience developing educational content and tools for clinical staff
Benefits & Perks
Competitive payMedical, dental, and vision insurance401K with matching fundsLife InsuranceEmployee discountsTuition ReimbursementStudent Loan Reimbursement