What are the responsibilities and job description for the Executive Director of Clinical Reimbursement position at PruittHealth?
JOB PURPOSE:
The Executive Director of Clinical Reimbursement leads and oversees the clinical reimbursement process across the organization's long-term care and post-acute care facilities. This role ensures compliance with federal and state regulations, optimizes reimbursement strategies, and drives operational excellence in clinical documentation and billing practices. The Executive Director serves as a strategic partner, working closely with interdisciplinary teams to maximize revenue integrity while maintaining the highest standards of patient care.
KEY RESPONSIBILITIES:
- Develop, implement, and oversee company-wide clinical reimbursement strategies, policies, and best practices.
- Analyze reimbursement trends and identify opportunities to enhance revenue performance while aligning with regulatory requirements.
- Provide guidance on Medicare, Medicaid, Managed Care, Skilled Intensity, and other payer reimbursement processes.
- Leads the RAI Process and the use of various supporting software applications to ensure an appropriate level of Resident care and equitable and timely reimbursement of the care provided.
- Provides expertise, consultation, and guidance to appropriate partners to ensure MDS accuracy and adherence to company policy and procedures, as well as state and federal regulations and guidelines based on information derived from audits and other available data.
- Must possess and ensure operational excellence.
- Lead the training and development of regional and facility-level clinical reimbursement teams, including MDS coordinators, business office staff, and administrators.
- Monitor and evaluate reimbursement metrics to ensure optimal performance and compliance.
- Establish processes to improve accuracy in coding, documentation, and Minimum.
- Adheres to and oversees communication of privacy guidelines relative to the confidentiality of residents' protected health information.
- Participates in PI activities as appropriate.
- Overnight travel may be required.
KNOWLEDGE, SKILLS, ABILITIES:
- Expert knowledge of state and federal regulations, both clinical and financial as it relates to the RAI process and reimbursement systems.
- Current Licensed Registered Nurse or Allied Health Care Professional in state of residence. Credential Nurse Assessment Coordinator preferred.
- Experience in MatrixCare, Pointright a plus
- Extended use of Microsoft office products
QUALIFICATIONS - EXTERNAL:
MINIMUM EDUCATION REQUIRED:
Bachelors degree from an accredited school of Nursing or other Allied Health Care Institution
MINIMUM EXPERIENCE REQUIRED:
Ten years- (10) years health care management, MDS Assessment & care Planning experience in multi-facility, long-term care organizations preferred.
Five (5 ) years clinical responsibility and experience with RAI process (MDS) required
MINIMUM LICENSURE/CERTIFICATION REQUIRED BY LAW:
Current, active license as a Registered Nurse or Allied Health Professional -Compact License required.
We are committed to loving, giving, and caring. United in making a difference.
We are an Equal Employment Opportunity employer, all qualified applicants will receive consideration without regard to race, color, religion, sex, national origin, disability, or veteran status.
