Senior Clinical Reimbursement Consultant (RN)

The Senior Clinical Reimbursement Consultant (RN) is a highly skilled clinical reimbursement expert responsible for optimizing Medicare Part A PDPM reimbursement, Pennsylvania Medicaid Case Mix (CMI), MDS coding accuracy, clinical documentation, regulatory compliance, and financial performance across multiple skilled nursing facilities.

Serving as a trusted advisor to executive leadership and interdisciplinary teams, this position combines advanced clinical expertise with strategic consulting to identify reimbursement opportunities, remove operational barriers, improve documentation practices, and implement sustainable performance improvement initiatives.

The Senior Clinical Reimbursement Consultant partners with facility leadership to evaluate reimbursement processes, conduct on-site resident observations, validate MDS coding accuracy, identify clinical and operational opportunities, educate interdisciplinary teams, and implement innovative solutions that improve reimbursement integrity while supporting exceptional resident care.

This position requires independent decision-making, executive-level communication skills, strong clinical judgment, and the ability to influence organizational performance through collaboration, education, and strategic leadership.

• Serve as the clinical reimbursement consultant for assigned skilled nursing facilities.
• Provide strategic guidance to executive leadership regarding Medicare PDPM reimbursement, Pennsylvania Medicaid Case Mix (CMI), clinical documentation improvement, and reimbursement optimization.
• Identify operational, clinical, documentation, and workflow barriers that negatively impact reimbursement and financial performance.
• Perform root cause analyses to determine the underlying causes of reimbursement challenges and operational inefficiencies.
• Develop innovative, practical, and sustainable solutions that improve reimbursement outcomes while enhancing clinical quality and operational efficiency.
• Lead interdisciplinary problem-solving initiatives and facilitate implementation of corrective action plans.
• Translate complex reimbursement regulations into actionable strategies that improve organizational performance.
• Monitor implementation of recommendations and evaluate measurable outcomes.

• Conduct on-site resident observations and focus clinical assessments to validate MDS coding accuracy and supporting documentation.
• Observe resident performance during routine care and therapy to validate coding for:
  • Section GG
  • Activities of Daily Living (ADLs)
  • Mobility and transfers
  • Self-care
  • Cognition
  • Mood and behaviors
  • Communication
  • Swallowing disorders
  • Skin integrity
  • Restorative nursing
  • Respiratory services
  • Skilled nursing services
  • Special treatments and procedures
• Compare resident observations with nursing, therapy, physician, and MDS documentation to identify discrepancies.
• Validate that documentation accurately reflects resident acuity, clinical complexity, skilled services, and resource utilization.
• Identify documentation deficiencies affecting reimbursement, Quality Measures, and regulatory compliance.
• Provide immediate education and coaching based on resident observation findings.
• Utilize advanced clinical assessment skills to support reimbursement integrity and regulatory compliance.

• Conduct comprehensive Medicare Part A PDPM reimbursement reviews.
• Validate ICD-10-CM coding and clinical category assignment.
• Review PT, OT, SLP, Nursing, and NTA classifications for reimbursement accuracy.
• Identify opportunities for Interim Payment Assessments (IPAs).
• Evaluate assessment timing and Interrupted Stay policy compliance.
• Validate Section GG coding through chart review and resident observation.
• Review physician documentation supporting primary diagnoses and skilled services.
• Identify reimbursement opportunities before claim submission.
• Collaborate with interdisciplinary teams to maximize reimbursement while maintaining regulatory compliance.

• Monitor Case Mix Index performance across assigned facilities.
• Audit MDS coding affects Pennsylvania Medicaid reimbursement.
• Review picture dates, weighted days, Medicaid eligibility, and quarterly Case Mix submissions.
• Analyze reimbursement trends and recommend strategies that improve financial performance.
• Ensure compliance with Pennsylvania Medicaid Case Mix methodology and reporting requirements.

• Perform concurrent and retrospective documentation audits.
• Evaluate documentation supporting Medicare and Medicaid reimbursement.
• Identify missing, conflicting, or unsupported clinical documentation.
• Collaborate with physicians and interdisciplinary teams to improve documentation specificity.
• Develop documentation improvement initiatives that strengthen reimbursement integrity and reduce audit risk.

• Serve as the organization's reimbursement subject matter expert.
• Mentor MDS Coordinators, Directors of Nursing, therapy teams, administrators, and interdisciplinary staff.
• Develop and deliver education on Medicare PDPM, Pennsylvania Medicaid Case Mix, MDS coding, ICD-10-CM coding, documentation improvement, regulatory compliance, and survey readiness.
• Promote accountability, collaboration, innovation, and continuous professional development.

• Ensure compliance with CMS regulations, the RAI User's Manual, Medicare billing requirements, Pennsylvania Medicaid Case Mix methodology, and organizational policies.
• Prepare facilities for Medicare ADRs, UPIC reviews, Medicaid audits, and regulatory surveys.
• Identify reimbursement risks before they become financial liabilities.
• Maintain the highest standards of ethical reimbursement practices and clinical integrity.

• Analyze reimbursement performance and identify trends affecting financial outcomes.
• Develop measurable action plans that improve reimbursement accuracy, documentation quality, and operational efficiency.
• Prepare executive-level reports, dashboards, and recommendations.
• Lead performance improvement initiatives that produce sustainable financial and operational results.

Regular travel to skilled nursing facilities is required to conduct resident observations, reimbursement assessments, interdisciplinary meetings, executive consultation, staff education, and performance improvement initiatives.

• Current Registered Nurse (RN) license in good standing.
• Minimum of 3–5 years of progressive clinical reimbursement experience.
• Advanced expertise in:
  • Medicare Part A PDPM
  • Pennsylvania Medicaid Case Mix (CMI)
  • MDS 3.0
  • CMS RAI User's Manual
  • ICD-10-CM Coding
  • Clinical Documentation Improvement
• Demonstrated expertise conducting resident observations to validate MDS coding and reimbursement accuracy.
• Proven ability to identify reimbursement barriers and implement innovative operational solutions that improve financial performance.
• Excellent communication, presentation, analytical, organizational, and problem-solving skills.
• Ability to travel regularly to client facilities.

• RAC-CT Certification.
• Corporate reimbursement or consulting experience.
• Multi-facility skilled nursing experience.
• Experience with PointClickCare, IntelliLogix, or comparable electronic medical record

• Strategic Reimbursement Consulting
• Medicare PDPM Optimization
• Pennsylvania Medicaid Case Mix (CMI)
• Resident Observation & Clinical Assessment
• MDS Coding Validation
• Clinical Documentation Improvement
• ICD-10-CM Coding
• Financial Performance Analysis
• Root Cause Analysis
• Operational Performance Improvement
• Executive Communication
• Education & Mentorship
• Regulatory Compliance
• Process Improvement
• Interdisciplinary Leadership

• Improved Medicare Part A PDPM reimbursement performance.
• Increased Pennsylvania Medicaid Case Mix Index (CMI).
• Improved documentation quality and MDS coding accuracy.
• Reduction in coding discrepancies identified through resident observations.
• Increased reimbursement capture through documentation improvement initiatives.
• Successful Medicare and Medicaid audit outcomes.
• Reduced reimbursement denials and payment adjustments.
• Measurable operational improvements following implementation of strategic recommendations.
• Positive financial impact across assigned facilities.