Senior Clinical Reimbursement Consultant (RN)

Limitlessli

1d•Remote

About The Position

Limitlessli is seeking a highly skilled Senior Clinical Reimbursement Consultant (RN) to join their team. This role is responsible for optimizing reimbursement across multiple skilled nursing facilities by focusing on Medicare Part A PDPM, Pennsylvania Medicaid Case Mix (CMI), MDS coding accuracy, clinical documentation, regulatory compliance, and financial performance. The consultant will act as a trusted advisor to leadership, identifying opportunities, removing barriers, improving documentation, and implementing sustainable performance improvement initiatives. This involves evaluating processes, conducting on-site resident observations, validating MDS coding, educating teams, and implementing solutions that enhance reimbursement integrity while supporting resident care. The position demands independent decision-making, executive-level communication, strong clinical judgment, and the ability to influence organizational performance through collaboration and strategic leadership.

Requirements

Current Registered Nurse (RN) license in good standing.
Minimum of 3–5 years of progressive clinical reimbursement experience.
Advanced expertise in Medicare Part A PDPM
Advanced expertise in Pennsylvania Medicaid Case Mix (CMI)
Advanced expertise in MDS 3.0
Advanced expertise in CMS RAI User's Manual
Advanced expertise in ICD-10-CM Coding
Advanced expertise in Clinical Documentation Improvement
Demonstrated expertise conducting resident observations to validate MDS coding and reimbursement accuracy.
Proven ability to identify reimbursement barriers and implement innovative operational solutions that improve financial performance.
Excellent communication, presentation, analytical, organizational, and problem-solving skills.
Ability to travel regularly to client facilities.

Nice To Haves

RAC-CT Certification.
Corporate reimbursement or consulting experience.
Multi-facility skilled nursing experience.
Experience with PointClickCare, IntelliLogix, or comparable electronic medical record

Responsibilities

Serve as the clinical reimbursement consultant for assigned skilled nursing facilities.
Provide strategic guidance to executive leadership regarding Medicare PDPM reimbursement, Pennsylvania Medicaid Case Mix (CMI), clinical documentation improvement, and reimbursement optimization.
Identify operational, clinical, documentation, and workflow barriers that negatively impact reimbursement and financial performance.
Perform root cause analyses to determine the underlying causes of reimbursement challenges and operational inefficiencies.
Develop innovative, practical, and sustainable solutions that improve reimbursement outcomes while enhancing clinical quality and operational efficiency.
Lead interdisciplinary problem-solving initiatives and facilitate implementation of corrective action plans.
Translate complex reimbursement regulations into actionable strategies that improve organizational performance.
Monitor implementation of recommendations and evaluate measurable outcomes.
Conduct on-site resident observations and focus clinical assessments to validate MDS coding accuracy and supporting documentation.
Observe resident performance during routine care and therapy to validate coding for Section GG, Activities of Daily Living (ADLs), Mobility and transfers, Self-care, Cognition, Mood and behaviors, Communication, Swallowing disorders, Skin integrity, Restorative nursing, Respiratory services, Skilled nursing services, Special treatments and procedures.
Compare resident observations with nursing, therapy, physician, and MDS documentation to identify discrepancies.
Validate that documentation accurately reflects resident acuity, clinical complexity, skilled services, and resource utilization.
Identify documentation deficiencies affecting reimbursement, Quality Measures, and regulatory compliance.
Provide immediate education and coaching based on resident observation findings.
Utilize advanced clinical assessment skills to support reimbursement integrity and regulatory compliance.
Conduct comprehensive Medicare Part A PDPM reimbursement reviews.
Validate ICD-10-CM coding and clinical category assignment.
Review PT, OT, SLP, Nursing, and NTA classifications for reimbursement accuracy.
Identify opportunities for Interim Payment Assessments (IPAs).
Evaluate assessment timing and Interrupted Stay policy compliance.
Validate Section GG coding through chart review and resident observation.
Review physician documentation supporting primary diagnoses and skilled services.
Identify reimbursement opportunities before claim submission.
Collaborate with interdisciplinary teams to maximize reimbursement while maintaining regulatory compliance.
Monitor Case Mix Index performance across assigned facilities.
Audit MDS coding affects Pennsylvania Medicaid reimbursement.
Review picture dates, weighted days, Medicaid eligibility, and quarterly Case Mix submissions.
Analyze reimbursement trends and recommend strategies that improve financial performance.
Ensure compliance with Pennsylvania Medicaid Case Mix methodology and reporting requirements.
Perform concurrent and retrospective documentation audits.
Evaluate documentation supporting Medicare and Medicaid reimbursement.
Identify missing, conflicting, or unsupported clinical documentation.
Collaborate with physicians and interdisciplinary teams to improve documentation specificity.
Develop documentation improvement initiatives that strengthen reimbursement integrity and reduce audit risk.
Serve as the organization's reimbursement subject matter expert.
Mentor MDS Coordinators, Directors of Nursing, therapy teams, administrators, and interdisciplinary staff.
Develop and deliver education on Medicare PDPM, Pennsylvania Medicaid Case Mix, MDS coding, ICD-10-CM coding, documentation improvement, regulatory compliance, and survey readiness.
Promote accountability, collaboration, innovation, and continuous professional development.
Ensure compliance with CMS regulations, the RAI User's Manual, Medicare billing requirements, Pennsylvania Medicaid Case Mix methodology, and organizational policies.
Prepare facilities for Medicare ADRs, UPIC reviews, Medicaid audits, and regulatory surveys.
Identify reimbursement risks before they become financial liabilities.
Maintain the highest standards of ethical reimbursement practices and clinical integrity.
Analyze reimbursement performance and identify trends affecting financial outcomes.
Develop measurable action plans that improve reimbursement accuracy, documentation quality, and operational efficiency.
Prepare executive-level reports, dashboards, and recommendations.
Lead performance improvement initiatives that produce sustainable financial and operational results.