Director of Clinical Reimbursement Services

Overview

At FutureCare the Director of Clinical Reimbursement Services is a senior leadership role which requires a blend of clinical expertise, regulatory knowledge, and financial acumen in addition to embracing a commitment to balancing fiscal responsibility with compassionate, high-quality resident care, contributing to the overall success and sustainability of FutureCare’s 16 Skilled Nursing Facilities as well as meeting FutureCare’s mission and goals.

Under the direction of the Vice President of Clinical Services, the Director of Clinical Reimbursement Services is responsible for designing, implementing, and monitoring clinical reimbursement processes to ensure that the system for resident care is compliant with documentation requirements in accordance with FutureCare’s policies and procedures, as well as compliant with state and federal regulations (particularly Medicare and Medicaid). In addition, the Director of Clinical Reimbursement Services will be responsible for overseeing clinical documentation and reimbursement processes while providing oversight and ongoing support to the Regional MDS (Minimum Data Set) Specialists, Regional Floating RNACs, Regional Clinical Review Nurse(s), and other regional staff regarding clinical reimbursement as well as collaborating with clinical staff, facility leadership, and financial staff to optimize revenue cycles and support all facilities’ financial health. Strong communication, organizational, leadership, problem-solving and people skills are essential to the success of the Director of Clinical Reimbursement Services.

If you are passionate and committed to leading a team who will provide quality care for residents while ensuring FutureCare’s programs and policies are being followed in order to provide the best outcomes for our residents, staff and FutureCare facilities, consider working as the Director of Clinical Reimbursement Services.

***Salary Range $140,807.68 - $211,211.52 Full Time Annual***

$7,500 Sign-On Bonus

#INDDIR

Salary Disclosure Statement

The salary mentioned above reflects the potential base pay range for this role. Bonuses or other incentives  (if applicable) are offered separately. Offers will consider such factors as overall experience, job-related qualifications, location, certifications/training, etc.

Responsibilities

• Develop and implement reimbursement strategies to ensure compliance with Medicare, Medicaid, and other payer guidelines, including accurate MDS assessments and the requirements for resident care plans.
• Oversee the clinical reimbursement team, including coordinators and specialists, providing training on documentation best practices, coding accuracy, and regulatory updates to minimize claim denials and audits.
• Monitor and analyze reimbursement trends, financial reports, and payer policies to identify opportunities for revenue enhancement and cost efficiencies in clinical services.
• Collaborate with nursing, therapy (rehab) and administrative staff to ensure clinical documentation supports optimal reimbursement levels while aligning with resident-centered care standards.
• Lead quality assurance initiatives related to reimbursement, including internal audits, mock surveys, and corrective action plans to maintain facility accreditation and avoid penalties.
• Stay abreast of changes in healthcare reimbursement laws, such as updates to federal and state regulations, RAI manual content, PDPM changes, revise job descriptions, policies and procedures, program content and clinical documentation as necessary and advise leadership on their impact on operations.
• Manage the preparation and submission of reimbursement claims, appeals, and responses to payer audits, ensuring timely and accurate processing.
• Foster interdisciplinary teamwork to integrate clinical care with reimbursement goals, promoting efficient resource allocation and resident outcomes.
• Ensure Regional MDS Specialists visit assigned facilities on a weekly basis to provide day-to-day support to staff regarding the MDS/RAI process, and PDPM reimbursement systems.
• Ensure Regional MDS Specialists perform weekly defined audits of facility and staff performance within scope and to communicate findings to facility and management staff.
• Ensure MDS Specialists analyze facility staff strengths and weaknesses within scope based on audits and observations and to communicate findings to facility and management staff.
• Participate in facility selection, training, and evaluation of MDS staff/Registered Nurse Assessment Coordinator (RNAC) staff.  To make recommendations to facility based on findings.
• Prepare and present formal and informal facility-based educational programs/in-services to strengthen staff performance.
• Act as a day-to-day resource for:
• Accurate MDS/RAI completion
• Medicare Part A/ PDPM coverage guidelines
• ICD-XX coding for successful PDPM billing
• Orientation of new MDS staff/ RNACs in the MDS/RAI process and clinical reimbursement
• Maryland Medicaid Billing and Appeal Processes
• Prepare and submit accurate MDS electronic files within CMS regulations for electronic submission on a weekly basis.
• Complete Maryland Medicaid billing on a monthly basis, participates as needed in all State Medicaid Utilization Agents’ Reviews with Regional MDS Specialists and facility medical records staff, and assists with all PatientAssessment Adjustment appeals.
• Accurately communicate Medicare PDPM billing information and Maryland Medicaid billing information to FutureCare’s Billing Department in a timely
• manner to ensure proper billing on a monthly basis.
• Retrieve Quality Measure (QM) Analytic Reports andother notices/database reports and makes information available for review by authorized FutureCare staff on a regular basis and as requested for other regulatory agencies as required by law.
• Make recommendations for policy/procedure/practice within scope.
• Abide by the standards identified in FutureCare’s Statement of Corporate Ethics and the Corporate Compliance Plan.
• Provide initial and ongoing training of clinical computer software to applicable facility staff.
• Other duties as may be assigned.

Qualifications

• Must possess an active Registered Nurse (RN) in State of Maryland or multi-state compact RN licensure, certification in MDS (e.g., RAC-CT), reimbursement specialties (e.g., CPC or RHIT), or long-term care administration highly desirable
• Bachelor’s Degree in Nursing (BSN) or a related healthcare field required; Master’s Degree in Healthcare Administration, Nursing, or Business preferred
• Extensive MDS 3.0 training and software experience required
• Minimum of 5-7 years in clinical nursing or reimbursement roles within a nursing home or long-term care setting, with at least 3 years in a supervisory or leadership capacity; proven experience with Medicare/Medicaid reimbursement processes, MDS 3.0, and regulatory compliance (e.g., CMS Guidelines) is essential
• Strong knowledge of clinical documentation, ICD-XX/CPT coding, and healthcare reimbursement methodologies
• Excellent analytical, organizational, and problem-solving skills, with attention to detail for auditing records and financial data
• Leadership and effective communication abilities to train and work with all staff to accomplish goals; to resolve conflicts; and to liaise with external payers and regulators
• Computer “literate” with knowledge of clinical and other commonly used software such as Microsoft Office suite
• Proficiency in electronic health records (EHR) systems, and up-to-date knowledge of the Maryland Medicaid Billing process
• Up to date knowledge of MDS/RAI process

Equal Opportunity Employer 

FutureCare has a longstanding policy of providing a work environment that respects the dignity and worth of each individual and is free from all forms of employment discrimination, including harassment, because of race, color, sex, gender, pregnancy, age, religion, national origin, citizenship, marital status, sexual orientation, gender identity, gender expression, physical or mental disability, military or veteran status, or any other characteristic protected by law. We actively promote equality of opportunity for all and welcome all applications.