Director of Clinical Reimbursement- RNAC

Job Summary

We are seeking a highly skilled and strategic Director of Clinical Reimbursement- RNAC to lead our reimbursement and clinical documentation improvement initiatives. The ideal candidate will possess extensive experience in healthcare reimbursement, managed care, and clinical documentation, with a strong background in acute care settings. In this leadership role, you will oversee the development and implementation of reimbursement strategies, ensure compliance with healthcare regulations, and optimize revenue cycle processes.

Your expertise will be instrumental in aligning clinical documentation with coding standards to maximize reimbursement while maintaining high standards of patient care and regulatory adherence.

Responsibilities

• Lead the development and execution of clinical reimbursement strategies across inpatient, outpatient, and specialized care settings, including ICU, PICU, and trauma centers.
• Oversee utilization review and utilization management processes to ensure appropriate patient care and resource utilization aligned with Medicare, Medicaid, and commercial payer requirements.
• Manage clinical documentation improvement programs to enhance accuracy of medical records, coding (ICD-10/ICD-9/CPT), and DRG assignments for optimal reimbursement.
• Collaborate with health information management teams to ensure compliance with HIPAA regulations and maintain integrity of medical records within EMR/EHR systems such as Cerner, Epic, Athenahealth, and eClinicalWorks.
• Provide leadership in coding accuracy by supporting staff proficient in ICD coding, ICD-10/ICD-9 updates, CPT coding, and physiology/anatomy knowledge essential for precise documentation review.
• Drive initiatives to improve case management processes including discharge planning, hospice care coordination, and outpatient services to optimize patient flow and revenue.
• Stay current with industry standards such as NCQA standards and Medicare policies to ensure organizational compliance and maximize reimbursement opportunities.

Requirements

• Bachelor's degree in Nursing (RN) or related healthcare field; advanced certifications in coding or reimbursement preferred.
• Extensive experience in skilled and LTC healthcare organization environments with a focus on inpatient and outpatient medical management.
• Proven expertise in PCC; familiarity with health information management practices.
• Strong knowledge of managed care policies, Medicare regulations, ICD coding (ICD-10/ICD-9), CPT coding, DRG assignment, and utilization review protocols.
• Demonstrated leadership skills with experience managing multidisciplinary teams involved in clinical documentation improvement and case management.
• Excellent understanding of medical terminology, anatomy/physiology knowledge, medical records review processes, and healthcare compliance standards including HIPAA.
• Ability to analyze complex data sets related to medical documentation review and coding accuracy to inform strategic decisions. Join our organization as we advance healthcare delivery through expert clinical reimbursement leadership that ensures financial sustainability while upholding the highest standards of patient care!

Benefits

• 401(k)
• 401(k) matching
• Dental insurance
• Health insurance
• Life insurance
• Paid time off
• Vision insurance

Experience

• MDS: 1 year (Required)

License/

Certification

• RN License (Required)

Ability to Commute

• Sarasota, FL 34234 (Required)

Work Location: In person