Director, Clinical Reimbursement

Seeking an experienced Director of Clinical Reimbursement to oversee the management, review, and optimization of clinical service revenue streams. This position is responsible for ensuring compliance with all applicable rules and regulations, while strategically maximizing reimbursement opportunities. The Director will serve as a key resource for regulatory guidance, staff education, and process improvement related to Medicaid, Medicare, and Managed Care programs.

Key Responsibilities:

• Oversee clinical reimbursement processes to maximize Medicaid, Medicare, and Managed Care revenue.
• Educate staff on MDS guidelines, PPS requirements, and reimbursement best practices.
• Monitor regulatory changes and update internal policies accordingly.
• Conduct audits of MDS and clinical documentation to ensure compliance and optimize outcomes.
• Lead Triple-Check meetings and manage authorization and appeals processes.
• Analyze reimbursement trends, create improvement strategies, and provide monthly reports to leadership.
• Supervise and train staff, ensuring compliance with all organizational and regulatory standards.
• Support QAPI initiatives and participate in performance improvement activities.

Qualifications:

• Bachelor’s degree in healthcare or a related field required; Master’s degree preferred.
• Minimum of three (3) years of clinical experience in a long-term care setting, including supervisory or administrative roles.
• At least two (2) years of direct clinical reimbursement experience.
• Deep knowledge of RAI Manual, MDS processes, state grouping systems, Medicare/Medicaid compliance, and interdisciplinary services (rehab, dietary, social services).

Brooklyn, one of New York City’s five boroughs, is known for its diverse communities, artistic scene, and historic neighborhoods. With a population exceeding 2.5 million, it offers a vibrant blend of urban life and suburban charm, featuring iconic attractions like the Brooklyn Bridge and Prospect Park. Brooklyn boasts a thriving arts scene, numerous restaurants, and cultural institutions, making it an ideal location for professionals and families alike.