Regional Director of Reimbursement

Published: 6/14/2022

Job Description

Tide Health New England is hiring a Regional Director of Reimbursement to join our MDS team in Massachusetts!

The Regional Director of Reimbursement protects accurate, compliant revenue across all assigned facilities. The role leads MDS accuracy, PDPM capture, SNF QRP

compliance, billing compliance, CMI accuracy, and maximizing revenue. This leader manages facility MDS and reimbursement staff across multiple sites, as well as working closely with the VP of Reimbursement and Therapy Services. They serve as the region's subject matter expert on Medicare, Medicaid, and managed care reimbursement, and partner with operations, nursing, therapy, and business office leaders to close gaps before they become denials, penalties, or survey findings.

This is a full-time position with in-person responsibilities. Must be willing to travel throughout the region and support other facilities remotely. Can be an LPN or RN. Salary ranges from $130,000 to $175,000, depending on license and experience. Position supports skilled nursing facilities in Plymouth & Bristol Counties and on the Cape, as well as one facility in Worcester.

Requirements:

Must possess an active and unencumbered LPN or RN license in Massachusetts.
A minimum of five years experience in MDS, reimbursement, or clinical reimbursement experience in skilled nursing.
A minimum of three years of experience leading reimbursement or MDS staff across multiple sites.
Expert knowledge of MDS 3.0, the RAI manual, PDPM, SNF QRP, and Medicare Part A and B billing rules.
Working knowledge of state Medicaid case-mix and managed care reimbursement
Experience managing ADRs, audits, appeals, and denials.
Proficiency with PointClickCare, Net Health, Intellilogix, My-ZPak, and Excel.
Resident Assessment Coordinator Certified (RAC-CT) or Director of Assessment

certification (RAC-CTA / DNS-CT) preferred.

Certified coding or billing credential (e.g., CPC, CPCO) preferred.
Experience with compliance program operations, overpayment reviews, or self-disclosure preferred.

Duties:

Lead, train, coach, and mentor MDS personnel.
Monitor facility performance with a regional dashboard and intervene early at underperforming sites.
Represent reimbursement in regional leadership meetings and corporate initiatives.
Ensure MDS assessments are accurate, timely, and supported by medical record documentation.
Audit PDPM component capture (PT, OT, SLP, nursing, NTA) and identify missed or unsupported coding.
Educate interdisciplinary teams on documentation that supports accurate classification.
Oversee assessment scheduling, ARD selection, and transmission timeliness.
Monitor each facility's SNF QRP data completion against the 90% APU threshold and correct gaps before quarterly deadlines and report to VP of Reimbursement and Therapy.
Review iQIES provider preview, threshold, and QM reports every quarter.
Track Five-Star QM performance and partner with clinical leaders on improvement plans.
Review Part A and Part B billing practices for coverage, coding, and documentation compliance.
Audit claims and triple checks; identify unbillable or unsupported services before submission.
Lead internal reviews when a potential overpayment is found and coordinate with Compliance on report-and-return obligations.
Keep facilities current on CMS, MAC, and state Medicaid rule changes, in close communication with the VP of Reimbursement and Therapy Services.
Oversee responses to ADRs, TPE, RAC, UPIC, and managed care audits across the region, and work closely with the Appeals and Denials Department.
Support state Medicaid case-mix accuracy and documentation reviews.
Monitor managed care authorizations, level-of-care changes, and contract requirements.
Advise on payer mix and reimbursement opportunities.
Analyze PDPM rates, case mix index, and revenue per patient day by facility.
Report regional reimbursement performance to senior leadership.
Provide regional and on-site training on MDS, PDPM, QRP, and billing compliance.
Participate in facility QAPI as needed; lead performance improvement projects on reimbursement and data quality.

Benefits:

Weekly Pay
Holiday Pay
Career Advancement Opportunities
Exclusive Employer Discount Program
401(k) with Employer Match

Available for Full-Time Staff:

Employer-Paid Life Insurance
Vacation and Personal Time
Health, Dental, and Vision Insurance

We are an equal opportunity employer that values diversity at all levels. All individuals are encouraged to apply. We follow federal and state guidelines regarding staff vaccinations. Our policy requires all staff to be up to date with COVID and flu vaccinations, or acknowledge a declination of the vaccination(s).