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Clinical Director of Reimbursement Pioneer Health Care Management Inc - 2.0 Bingham Farms, MI Job Details Full-time 23 hours ago Qualifications Quality control corrective actions Healthcare onboarding training Collaborate with healthcare professionals Regulatory inspections Appeals Performance improvement leadership Management Overseeing health insurance pre-certification Medicare Audit report preparation Overseeing healthcare denial management HIPAA implementation HIPAA Healthcare documentation compliance audits Medical claim appeals Metrics Reporting Healthcare regulatory compliance investigations Orientation and onboarding programs (healthcare teaching and curriculum development) Quality reports Audit Reporting CMS regulatory compliance Retrospective medical coding audits Medicare regulations Clinical performance metrics Quality compliance management Clinical documentation Medical insurance appeals management Interdisciplinary policy and procedure development experience OBRA Centers for Medicare & Medicaid Services (CMS) billing regulations Full Job Description

PIONEER HEALTHCARE MANAGEMENT

Job Description Title:

Director of Reimbursement Reports to:

Director of Operations Effective Date:

10.14.2023

Review Date:

5.29.2025 Corporate Leadership Provide leadership and oversight to all facility MDS Coordinators and Regional Clinical Teams. Standardize MDS processes across all facilities. Develop and implement corporate MDS policies and procedures. Ensure consistency with CMS regulations and company standards. Assist facilities during leadership transitions and vacancies. Provide on-site support during surveys, focused reviews, and regulatory investigations. Serve as the corporate expert for MDS, PDPM, and reimbursement. Regulatory Compliance Ensure all facilities maintain compliance with: CMS Resident Assessment Instrument (RAI) Manual Medicare Part A regulations Medicaid reimbursement regulations Patient Driven Payment Model (PDPM) OBRA Requirements State Survey Requirements HIPAA Corporate Compliance Program Monitor compliance through routine auditing and reporting.

MDS Oversight Oversee:

Updated 10-17-23, 10-18-2023, 5.29.2025 Page 2 of 2 Assessment scheduling ARD management Assessment completion MDS accuracy Timely transmission Validation reports Assessment modifications Inactivation requests Error corrections

Monitor:

Entry Tracking OBRA Assessments PPS Assessments IPA Assessments Significant Change Assessments Quarterly Assessments Annual Assessments Discharge Assessments Reimbursement Oversight Provide oversight of: Medicare Part A PDPM classification Skilled documentation Triple Check process Medicare eligibility Benefit day management Notice of Medicare Non-Coverage (NOMNC) Denial prevention Appeals support Medicaid Case Mix accuracy Updated 10-17-23, 10-18-2023, 5.29.2025 Page 3 of 2 Diagnosis validation State reimbursement requirements Medicaid audits Managed Care Authorization management Documentation review Clinical updates Denial prevention Appeals support Clinical Documentation Improvement (CDI) Collaborate with nursing leadership, therapy, physicians, dietary, and social services to ensure documentation accurately supports: PDPM reimbursement Medical necessity Skilled services Diagnosis coding Functional status Clinical complexity PDPM Oversight Review and validate: Nursing Component Extensive Services Special Care High Special Care Low Clinically Complex Behavioral Symptoms Reduced Physical Function Updated 10-17-23, 10-18-2023, 5.29.2025 Page 4 of 2 Therapy Components Physical Therapy Occupational Therapy Speech Therapy NTA Component Review supporting documentation for: IV medications Respiratory therapy Dialysis Wounds Isolation Comorbidities High-cost services

MDS Coding Audits Audit:

Section A Section B Section C Section D Section E Section F Section G (if applicable) Section GG Section H Section I Section J Section K Section L Section M Section N Section O Section P Updated 10-17-23, 10-18-2023, 5.29.2025 Page 5 of 2 Section Q Clinical Documentation Audits Review documentation from: Nursing Physicians Nurse Practitioners Therapy Respiratory Dietary Social Services Activities Pharmacy Ensure documentation supports: Skilled services MDS coding Reimbursement Care planning Quality Measures Quality Measures Oversight Monitor corporate Quality Measures, including: Hospital Readmissions Falls with Major Injury Pressure Injuries Weight Loss Antipsychotic Use Catheter Utilization Urinary Tract Infections Vaccinations Functional Improvement Updated 10-17-23, 10-18-2023, 5.29.2025 Page 6 of 2 Decline in ADLs Develop action plans for facilities not meeting benchmarks. Five-Star Quality Rating Monitor and improve: Quality Measures Health Inspection outcomes Staffing metrics MDS accuracy affecting publicly reported measures Collaborate with facility leadership to improve Five-Star performance. Education & Training Develop and provide education on: CMS RAI Manual updates PDPM Section GG Section K Clinical documentation ICD-10 coding Medicare regulations Medicaid updates Managed Care requirements Triple Check process Quality Measures Provide orientation for new MDS Coordinators and ongoing competency validation. Auditing Responsibilities Updated 10-17-23, 10-18-2023, 5.29.2025 Page 7 of 2 Conduct routine corporate audits of: MDS completion MDS accuracy ARD scheduling Medicare documentation Medicaid case mix Managed Care Triple Check Care Plans CAAs Skilled documentation Diagnosis coding Section GG Section K Therapy documentation Physician documentation PDPM optimization Issue written reports with corrective actions and follow-up plans.

Operational Support Assist facilities with:

Survey preparation Mock surveys Focused MDS reviews Revenue recovery initiatives New facility acquisitions Facility transitions Interim MDS coverage Regulatory compliance initiatives Reporting Responsibilities Prepare and present monthly corporate reports including: Updated 10-17-23, 10-18-2023, 5.29.2025 Page 8 of 2 MDS completion compliance Transmission compliance PDPM reimbursement trends Medicare census Medicaid Case Mix Managed Care census Five-Star trends Quality Measures Triple Check compliance Revenue opportunities Audit findings Facility scorecards