Job Summary We are seeking a dynamic and highly skilled Director of Clinical Reimbursement to lead our organization's efforts in optimizing reimbursement strategies, ensuring compliance with healthcare regulations, and enhancing revenue cycle management. This pivotal role requires a strategic thinker with extensive experience in clinical documentation, medical coding, and healthcare reimbursement policies. The ideal candidate will possess a deep understanding of managed care, Medicare, Medicaid, and other payer systems, along with strong leadership capabilities to guide multidisciplinary teams toward operational excellence. Join us to shape innovative reimbursement programs that support quality patient care and organizational growth. Responsibilities Develop and implement comprehensive clinical reimbursement strategies aligned with industry standards and regulatory requirements, including CMS guidelines and state healthcare policies. Oversee the accurate coding of medical records using CPT, ICD-9, ICD-10, DRG, and other relevant coding systems to maximize reimbursement while maintaining compliance. Lead utilization management initiatives to optimize patient care pathways, reduce unnecessary costs, and ensure adherence to clinical documentation standards. Collaborate with clinical teams to improve documentation practices for inpatient, outpatient, long-term care, hospice, emergency medicine, pediatrics, and specialty services such as ICU and trauma centers. Manage the review of medical documentation for accuracy and completeness across EMR/EHR systems like Epic, Cerner, Athenahealth, eClinicalWorks, and others. Ensure compliance with HIPAA regulations and maintain up-to-date knowledge of healthcare laws including Medicare regulations, HEDIS standards, NCQA standards, and state-specific healthcare policies. Provide leadership in training staff on medical coding updates (ICD-10), documentation review processes, and billing procedures to enhance revenue integrity. Requirements Must be licensed nurse in the state of MA Extensive experience in clinical reimbursement within hospital settings or outpatient clinics; ICU or trauma center experience highly desirable. Proficiency with EMR/EHR systems such as Epic, Cerner, Athenahealth or eClinicalWorks; strong knowledge of electronic health records management is essential. Deep understanding of medical coding (CPT, ICD-9/10), DRG assignment, utilization review processes, and case management principles. Familiarity with Medicare/Medicaid regulations including MDS (Minimum Data Set) for long-term care facilities; knowledge of CMS policies is critical. Strong leadership skills with proven ability to manage multidisciplinary teams across clinical documentation improvement programs and revenue cycle functions. Excellent analytical skills with the ability to interpret complex healthcare data related to billing trends and reimbursement outcomes. Knowledge of HIPAA compliance standards along with state healthcare regulations governing medical records and documentation practices. Join us as a vital leader committed to advancing clinical reimbursement excellence—empowering our organization to deliver exceptional patient care while maintaining financial sustainability!

Pay:

From $150,000.00 per year

Benefits:

401(k) Dental insurance Health insurance Paid time off Professional development assistance Vision insurance

Work Location:

Hybrid remote in Melrose, MA 02176