The Clinical Reimbursement Manager (CRM) provides regional leadership, oversight, and strategic direction for clinical reimbursement operations across an assigned portfolio of skilled nursing facilities. This position is responsible for promoting accurate reimbursement, regulatory compliance, MDS accuracy, appropriate acuity capture, and strong clinical documentation practices while supporting facility leadership and MDS teams in achieving operational and financial performance goals.
The Clinical Reimbursement Manager serves as a subject-matter expert in Medicare Part A, PDPM, Texas Medicaid PDPM-LTC, MDS 3.0/RAI requirements, Quality Measures, QIPP, managed care, and reimbursement compliance. The CRM works collaboratively with facility and regional leadership to identify reimbursement opportunities, mitigate compliance risk, strengthen clinical systems, and improve overall reimbursement performance.
This is a field-based leadership position requiring regular travel throughout the assigned region and a consistent presence within assigned facilities.
Provide clinical reimbursement oversight and leadership for an assigned portfolio of skilled nursing facilities.
Monitor facility performance and identify opportunities related to Medicare, Medicaid, managed care, acuity capture, Case Mix Index (CMI), Quality Measures, and QIPP.
Develop and implement regional strategies to improve reimbursement performance while maintaining regulatory and documentation integrity.
Partner with Administrators, Directors of Nursing, MDS Coordinators, Regional Operations, Regional Clinical leadership, therapy providers, and other interdisciplinary partners.
Establish clear expectations and accountability for facility reimbursement processes and outcomes.
Maintain a consistent field presence within assigned facilities, spending a minimum of three (3) days per week facility-facing.
Coordinate facility visits and regional coverage based on reimbursement performance, compliance risk, staffing needs, Quality Measure performance, QIPP outcomes, MDS vacancies, operational priorities, and other identified business needs.
MDS and Regulatory Compliance
Provide expert guidance regarding the MDS 3.0, RAI Manual, Medicare Part A, PDPM, Texas Medicaid PDPM-LTC, and applicable CMS and state requirements.
Monitor MDS completion, accuracy, timeliness, and supporting clinical documentation.
Review reimbursement practices to ensure services and coded conditions are supported by the medical record.
Identify potential compliance concerns and implement corrective action plans.
Support facilities during internal audits, external audits, ADRs, medical reviews, and other reimbursement-related reviews.
Performance Management
Analyze facility and regional reimbursement metrics.
Identify underperforming facilities and develop targeted improvement plans.
Conduct routine follow-up to ensure corrective actions result in measurable improvement.
Provide leadership with concise reporting regarding performance, risks, trends, and opportunities.
Facility Support and Auditing
Conduct routine and focused facility visits based on operational need and performance.
Perform reimbursement, MDS, and clinical documentation audits.
Review medical records to validate coding and reimbursement support.
Evaluate facility MDS processes and interdisciplinary participation.
Provide immediate coaching and education when opportunities are identified.
Assist with stabilization of facilities experiencing MDS vacancies, turnover, survey concerns, reimbursement decline, or operational challenges.
Conduct routine facility rounding with facility leadership and interdisciplinary teams.
Maintain a visible and accessible presence within assigned facilities.
Education and Development
Provide ongoing education to MDS Coordinators, nursing leadership, interdisciplinary teams, and other appropriate staff.
Mentor and develop facility MDS personnel and field reimbursement staff.
Promote consistent reimbursement practices across assigned facilities.
Team Leadership
Provide direction and oversight to assigned field Clinical Reimbursement personnel and reimbursement support resources.
Participate in recruitment, onboarding, development, and performance management of reimbursement personnel.
Maintain communication and accountability across the regional reimbursement team.
