Director of Clinical Reimbursement Strategy (WESTERVILLE)

The Senior Director of Clinical Reimbursement provides strategic leadership, clinical and operational support for reimbursement functions. This role helps to ensure accurate, compliant, and optimized reimbursement under federal and state payment systems, including PDPM, Medicaid case mix, managed care, and other payor models. The Senior Director leads a team of Divisional and Regional consultants that drives clinical documentation integrity, and partners with operations, finance, and clinical leadership to align reimbursement performance with quality outcomes and regulatory compliance.

The full job description covers all associated skills, previous experience, and any qualifications that applicants are expected to have.

This role will have up to 90% travel to our skilled nursing facilities in Michigan, Ohio, Indiana, Virginia, and North Carolina.

Join us with an attractive benefits offering :

Competitive pay

Medical, dental, and vision insurance

401K with matching funds

Life Insurance

Employee discounts

Tuition Reimbursement

Student Loan Reimbursement

Responsibilities :

Provide strategic direction for the companys clinical reimbursement program across multiple states.

Oversee and mentor Clinical Reimbursement team to ensure consistent, compliant, and high-performing practices.

Monitor companywide MDS accuracy, RAI process adherence, and PDPM case mix management.

Collaborate with operations, clinical, and finance leaders to align clinical care, documentation, and reimbursement strategies.

Assist with facility audits, data integrity reviews, and reimbursement performance evaluations.

Lead initiatives to identify revenue opportunities while maintaining compliance with federal and state guidelines.

Develop processes to ensure timely and accurate completion of MDS assessments and transmission requirements.

Analyze payer trends, denials, and case mix data to guide process improvements.

Develop and implement education programs for MDS Coordinators, DONs, and IDT members related to PDPM, case mix, and reimbursement compliance.

Partner with Compliance and Quality teams to monitor risk areas related to coding, documentation, and audit findings.

Support budget development, forecast modeling, and rate adjustment initiatives in collaboration with finance.

Serve as the companys subject matter expert for reimbursement policy changes, CMS updates, and regulatory revisions.

Oversee internal audits and coordinate external reviews or appeals related to reimbursement.

Participate in acquisition due diligence, integration planning, and onboarding of new facilities into reimbursement systems.

Report regularly to senior leadership on key performance metrics, trends, and improvement plans.

Direct supervision of Regional Clinical Reimbursement Directors or Managers.

Ensure consistent interpretation and application of PDPM, Medicaid CMI, and managed care reimbursement systems.

Assists with the development and implementation of processes to support the accuracy, completeness, and timeliness of MDS assessments and related documentation.

Ensure compliance with CMS regulations, state requirements, and company policies governing clinical documentation and reimbursement.

Conduct onsite and remote clinical audits to validate coding accuracy and care documentation integrity.

Serve as the corporate liaison for survey and compliance inquiries related to MDS and reimbursement.

Develop and lead educational initiatives for MDS Coordinators, DONs, and interdisciplinary teams to strengthen knowledge of reimbursement systems and documentation standards.

Provide ongoing updates and training related to CMS changes, RAI manual updates, Value Based Purchasing Program, Quality Reporting Program, 5 Star Rating reports and payer requirements and monitors outcomes, assisting with development of performance improvement plans as needed.

Partner with Operations and Finance to analyze reimbursement trends, identify opportunities for improvement, and ensure integrity of clinical revenue streams.

Monitor case mix, PDPM performance, and quality indicators; implement corrective actions as needed.

Participates in budget planning, forecasting, and revenue optimization initiatives.

Participates / leads Quality Assurance and Performance Improvement (QAPI) initiatives through data analysis and identification of trends affecting reimbursement and resident outcomes, assisting with the development and / or implementation as applicable.

Serve as a resource for clinical systems integration and EHR optimization as it relates to MDS and reimbursement documentation.

Maintains in-depth knowledge of the clinical billing system and the MDS process to help investigate / troubleshoot user-related software issues.

Requirements :

Active RN license in state of residence or state(s) of practice required, Bachelors Degree in Nursing (BSN) is preferred.

Minimum of 3 years in a multi-site or corporate-level leadership role.

Proven expertise in PDPM, state Medicaid systems, and managed care reimbursement methodologies.

Demonstrated success in driving compliance, accuracy, and financial performance improvement across multiple facilities.

Must have, as a minimum, 5-year(s) experience with MDS (i.e., documentation, length of stay, Medicare / Medicaid reimbursement, RUGS, and regulations knowledge) long-term care facility or other healthcare related field.

Experienced in PPS, PDPM, Case-Mix, and OBRA assessments.

Understanding of CMS regulations, RAI process and coding compliance

RN licensed in the state, CPR certification, and RAC-CT certification preferred

Ciena Healthcare

We are a national organization of skilled nursing, subacute, rehabilitative, and assisted living providers dedicated to achieving the highest standards of care in five states including Michigan, Ohio, Virginia, North Carolina, and Indiana.

We serve our residents with compassion, concern, and excellence, believing that every one of them is a unique person who deserves our best each day that we care for them. Join us, if you have a passion for improving the lives of those around you and working with others who feel the same way.

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