Director of Clinical Reimbursement & Quality Improvement

Job Description

The Director of Clinical Reimbursement and Quality Improvement is responsible for overseeing the Minimum Data Set (MDS) and Resident Assessment Instrument (RAI) processes to ensure accuracy, compliance, and optimal reimbursement under the Patient-Driven Payment Model (PDPM). This position also assists in leading quality improvement initiatives by monitoring key clinical and quality outcomes, identifying trends, and developing process improvements to enhance resident care and organizational performance.

Essential Duties and Responsibilities

• Directs and coordinates the MDS and RAI process to ensure timely and accurate completion and submission in compliance with federal and state regulations.

• Monitors accuracy of assessments and supporting documentation to ensure compliance with MDS 3.0 and PDPM requirements.

• Collaborates with nursing, therapy, and interdisciplinary team members to ensure assessments reflect each resident's clinical status and care needs.

• Provides education and support to staff on RAI guidelines, MDS coding, and documentation standards.

• Tracks and analyzes CMS Quality Measures (QMs), Five-Star ratings, and other performance indicators.

• Leads or participates in Quality Assurance and Performance Improvement (QAPI) meetings and initiatives.

• Identifies trends or opportunities for improvement and partners with department leaders to develop and implement action plans.

• Ensures accurate case mix index (CMI) calculations and monitors reimbursement outcomes related to PDPM components.

• Maintains current knowledge of regulatory updates, survey processes, and reimbursement changes affecting the MDS and quality programs.

• Serves as a resource for compliance with clinical documentation standards, care planning, and quality reporting.

Qualifications

• Required - Registered Nurse (RN) currently licensed and in good standing with the state board of nursing.

• Preferred - RAC-CT Certified

• Minimum 2 years of MDS coordination or related experience in a skilled nursing facility required.

• Demonstrated knowledge of MDS 3.0, RAI guidelines, and PDPM reimbursement methodologies.

• Strong understanding of CMS Quality Measures, Five-Star system, and QAPI processes.

• Experience leading quality improvement initiatives preferred.

• Excellent organizational, analytical, and communication skills.

• Proficiency with electronic medical records and MDS software systems.

Key Competencies

• Attention to detail and regulatory compliance.

• Leadership and team collaboration.

• Data analysis and performance monitoring.

• Education and staff development.

• Continuous quality improvement mindset.

• Primarily on-site within the facility; standard weekday hours with flexibility for special projects or audits.

• Regular interaction with residents, staff, and regulatory personnel.

This position plays a critical role in ensuring the facility's clinical excellence, financial integrity, and continuous quality improvement.

What We Offer:

• 401(k) Matching at 3%

• Educational Loan Reimbursement - Up to $30,000

• Comprehensive Health, Dental & Vision Insurance

• Disability Insurance & Life Insurance

• Free Gym Membership to keep you at your best

• Paid Vacation & Sick Time - Because you deserve it!

• License Reimbursement - We support your professional growth!

• A Fun, Team-Oriented Atmosphere where learning is encouraged, and success is celebrated!