Clinical Reimbursement Resource

Job Overview We are seeking a highly skilled and detail-oriented Clinical Reimbursement Resource to join our healthcare team. This pivotal role involves managing and optimizing reimbursement processes, ensuring compliance with healthcare regulations, and supporting clinical documentation improvement initiatives. The ideal candidate will possess extensive knowledge of medical coding, managed care, and hospital-based reimbursement systems, with a strong background in clinical documentation, utilization review, and health information management. As a Clinical Reimbursement Resource, you will play a critical role in enhancing revenue cycle efficiency while maintaining the highest standards of patient care documentation. Duties Serve as subject matter expert in Medicare Part A, Managed Care, and

AHCCCS LTC

Levels/ Specialty contract reimbursement methodologies Partners with IDT resources and facility teams in the field to align best practices, elevate documentation standards, and support accurate coding and assessment processes Monitor and analyze reimbursement trends, regulatory changes, and performance metrics to identify opportunities and mitigate risks Develop and implement systems, tools, and training programs to support strong PDPM processes and defensible documentation Contribute to SNF VBP initiatives by integrating reimbursement strategies with quality performance goals Provide documentation reviews while providing learning opportunities to ensure defensible claims to minimize denials Deep knowledge of CMS regulations, PDPM, RAI guidelines, ICD-10 coding and managed care requirements Proven success in leading facility team(s) to elevate clinical and reimbursement outcomes Strong analytical skills with experience in data-driven decision-making and predictive analysis RN, LPN, or licensed therapist (PT/OT/ST) credentials RAC-CT (or equivalent) certification strongly preferred Minimum 5 years of experience with clinical reimbursement leadership in skilled nursing Strong communication, leadership, and team-building skills Ability to travel across markets as needed Experience Proven experience in medical coding (ICD-9/ICD-10), CPT coding, and DRG assignment within hospital or inpatient settings. Strong background in managed care environments with familiarity in Medicare billing processes. Extensive clinical experience in acute care settings such as ICU, PICU, emergency departments, or surgical units; experience in critical care or trauma centers is highly desirable. Prior work involving utilization review or utilization management programs focused on outpatient or inpatient services. Knowledge of electronic health record (EHR) systems including Epic, Cerner, Athenahealth; proficiency with medical documentation review is essential. Experience working within home care or hospice environments is a plus; familiarity with discharge planning processes is advantageous. Background in nursing or healthcare-related fields with an understanding of anatomy, physiology, nursing practices, and medical terminology enhances effectiveness in this role. Demonstrated ability to navigate complex healthcare regulations such as HIPAA compliance standards while managing sensitive patient information. Join our team as a Clinical Reimbursement Resource to leverage your expertise in clinical documentation improvement and revenue cycle management—contributing directly to the delivery of high-quality patient care while ensuring financial sustainability across diverse healthcare settings!

Pay:

$27.98 - $33.69 per hour

Benefits:

401(k) Dental insurance Employee assistance program Employee discount Flexible spending account Health insurance Life insurance Paid time off Tuition reimbursement Vision insurance

Work Location:

In person