Regional Clinical Reimbursement Specialist

This is a fully remote position, open to applicants in Florida.

📋 Description

• Collaborate with Directors of Nursing, Medical Directors, and consultant pharmacists to ensure clinically appropriate psychotropic stewardship.

• Lead initiatives focused on preventing falls with injuries, pressure injuries, and infections.

• Enhance restorative nursing practices, continence programs, and mobility strategies.

• Minimize avoidable hospitalizations by recognizing early changes in conditions, enhancing physician communication, and engaging families.

• Promote influenza vaccination and advocate for restraint-free care.

• Manage QAPI performance improvement projects with clearly defined goals.

• Equip care teams with resident-specific reports and actionable clinical next steps.

• Conduct rounds on units to observe care practices, coach staff, and ensure care plans align with bedside execution.

• Oversee facility staffing metrics to drive performance improvements.

• Collaborate with HR and nursing leaders to enhance RN retention, onboarding, and competency development.

• Validate PBJ submissions and staffing hours for cost reporting.

• Audit MDS coding to ensure accuracy.

• Review CASPER/QM reports monthly and execute pre-snapshot data accuracy evaluations.

• Ensure compliance with the RAI Manual, CMS and AHCA regulations, and company compliance policies.

• Maintain facility-level QIP scorecards and quarterly improvement plans.

• Target near-miss measures and track year-over-year improvement credits.

• Manage facility credentialing roadmaps.

• Monitor changes in AHCA regulations and the 2027 rebase.

• Support accuracy in Medicare PDPM and managed care MDS.

⛳️ Requirements

• Active RN license in Florida.

• A minimum of 3 years of experience in multi-facility MDS/clinical reimbursement.

• Extensive knowledge of the RAI Manual, CMS Quality Measures, and Five-Star rating system.

• Familiarity with Florida Medicaid PPS and QIP scoring systems.

• Strong proficiency in Excel and data analysis.

• Capability to influence others without direct authority.

• RAC-CT/RAC-CTA certification is preferred.

• Experience in QAPI leadership with measurable quality measure improvements is preferred.

• Experience with Joint Commission or Quality Award accreditation is preferred.

• Proficient in PointClickCare is preferred.

• Ability to sit for extended periods while performing data analysis, documentation reviews, reporting, and administrative tasks.

• Willingness to stand and walk regularly within healthcare facilities to conduct clinical rounds and observe resident care.

• Capable of using a computer, telephone, and other office equipment for extended durations.

• Ability to occasionally bend, reach, and lift or carry light materials while conducting facility visits and clinical assessments.

🏝️ Benefits

• Equal opportunity employment.

• Travel between assigned facilities for meetings, audits, training, and program oversight.