The Clinical Reimbursement Program Manager is responsible for the development and implementation of clinical reimbursement programs, compliance tools, and educational initiatives to support accurate, compliant, and optimized reimbursement processes across the organization. The role serves as a strategic partner to facility, regional and corporate leadership, ensuring consistency and best practices in MDS processes, PDPM optimization (reimbursement optimization), and regulatory compliance.
This role will oversee Michigan and Ohio skilled nursing facilities.
Join us with an attractive benefits offering:
- Competitive pay
- Medical, dental, and vision insurance
- 401K with matching funds
- Life Insurance
- Employee discounts
- Tuition Reimbursement
- Student Loan Reimbursement
Responsibilities:
- Design and implement clinical reimbursement programs to support accurate RAI/MDS assessments and PDPM accuracy.
- Develop and maintain compliance tools, audit processes, and documentation standards related to reimbursement.
- Conduct root cause analyses of reimbursement trends, denials, and documentation deficiencies; recommend corrective actions.
- Provide ongoing education, training, and competency validation to Clinical Reimbursement Specialists, MDS Coordinators, IDT members, and nursing staff on reimbursement best practices.
- Monitor regulatory changes affecting Medicare, Medicaid, and other payor sources; update internal processes and tools accordingly.
- Collaborate with clinical and operational leadership to align reimbursement strategies with resident care goals and quality outcomes.
- Support pre- and post-acute reimbursement audits and assist in developing response plans for external reviews.
- Participate in QAPI initiatives and provide data to support performance improvement.
- Assist in onboarding new clinical reimbursement staff and serve as a subject matter expert.
Requirements:
- Licensed Registered Nurse (RN) with current, active license in good standing.
- Minimum of 3 years of experience in clinical reimbursement, MDS, or case mix management in a skilled nursing facility.
- RAC-CT certification preferred.
- Demonstrated experience developing educational content and tools for clinical staff.
- In-depth knowledge of PDPM, MDS 3.0, Medicare/Medicaid regulations, SNF PPS reimbursement systems, and regulatory requirements.
Ability to travel as needed.
Ciena Healthcare
We are a national organization of skilled nursing, subacute, rehabilitative, and assisted living providers dedicated to achieving the highest standards of care in five states including Michigan, Ohio, Virginia, North Carolina, and Indiana.
We serve our residents with compassion, concern, and excellence, believing that every one of them is a unique person who deserves our best each day that we care for them. Join us, if you have a passion for improving the lives of those around you and working with others who feel the same way.
IND123
