[Hiring] Director of Clinical Reimbursement @Stellar Health Group

Role Description

The 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
• Finance leadership

This role will also lead:

• ADR, TPE, and RAC audit responses
• Oversee CMI and PDPM processes
• Support MDS staffing and education
• Coordinate reimbursement-related operations across facilities

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

Requirements

• 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
• 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
• 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
• 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
• 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
• 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

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