Clinical Director of Reimbursement

PIONEER HEALTHCARE MANAGEMENT Job Description Title: Director of Reimbursement Reports to: Director of Operations Effective Date: 10.14.2023 Review Date: 5.29.2025 Corporate Leadership  Provide leadership and oversight to all facility MDS Coordinators and Regional Clinical Teams.  Standardize MDS processes across all facilities.

 Develop and implement corporate MDS policies and procedures.  Ensure consistency with CMS regulations and company standards.  Assist facilities during leadership transitions and vacancies.  Provide on-site support during surveys, focused reviews, and regulatory investigations.  Serve as the corporate expert for MDS, PDPM, and reimbursement.

Regulatory Compliance Ensure all facilities maintain compliance with:  CMS Resident Assessment Instrument (RAI) Manual  Medicare Part A regulations  Medicaid reimbursement regulations  Patient Driven Payment Model (PDPM)  OBRA Requirements  State Survey Requirements  HIPAA  Corporate Compliance Program Monitor compliance through routine auditing and reporting.

MDS Oversight Oversee: Updated 10-17-23, 10-18-2023, 5.29.2025 Page 2 of 2  Assessment scheduling  ARD management  Assessment completion  MDS accuracy  Timely transmission  Validation reports  Assessment modifications  Inactivation requests  Error corrections Monitor:  Entry Tracking  OBRA Assessments  PPS Assessments  IPA Assessments  Significant Change Assessments  Quarterly Assessments  Annual Assessments  Discharge Assessments Reimbursement Oversight Provide oversight of: Medicare Part A  PDPM classification  Skilled documentation  Triple Check process  Medicare eligibility  Benefit day management  Notice of Medicare Non-Coverage (NOMNC)  Denial prevention  Appeals support Medicaid  Case Mix accuracy Updated 10-17-23, 10-18-2023, 5.

29.2025 Page 3 of 2  Diagnosis validation  State reimbursement requirements  Medicaid audits Managed Care  Authorization management  Documentation review  Clinical updates  Denial prevention  Appeals support Clinical Documentation Improvement (CDI) Collaborate with nursing leadership, therapy, physicians, dietary, and social services to ensure documentation accurately supports:  PDPM reimbursement  Medical necessity  Skilled services  Diagnosis coding  Functional status  Clinical complexity PDPM Oversight Review and validate: Nursing Component  Extensive Services  Special Care High  Special Care Low  Clinically Complex  Behavioral Symptoms  Reduced Physical Function Updated 10-17-23, 10-18-2023, 5.

29.2025 Page 4 of 2 Therapy Components  Physical Therapy  Occupational Therapy  Speech Therapy NTA Component Review supporting documentation for:  IV medications  Respiratory therapy  Dialysis  Wounds  Isolation  Comorbidities  High-cost services MDS Coding Audits Audit:  Section A  Section B  Section C  Section D  Section E  Section F  Section G (if applicable)  Section GG  Section H  Section I  Section J  Section K  Section L  Section M  Section N  Section O  Section P Updated 10-17-23, 10-18-2023, 5.

29.2025 Page 5 of 2  Section Q Clinical Documentation Audits Review documentation from:  Nursing  Physicians  Nurse Practitioners  Therapy  Respiratory  Dietary  Social Services  Activities  Pharmacy Ensure documentation supports:  Skilled services  MDS coding  Reimbursement  Care planning  Quality Measures Quality Measures Oversight Monitor corporate Quality Measures, including:  Hospital Readmissions  Falls with Major Injury  Pressure Injuries  Weight Loss  Antipsychotic Use  Catheter Utilization  Urinary Tract Infections  Vaccinations  Functional Improvement Updated 10-17-23, 10-18-2023, 5.

29.2025 Page 6 of 2  Decline in ADLs Develop action plans for facilities not meeting benchmarks. Five-Star Quality Rating Monitor and improve:  Quality Measures  Health Inspection outcomes  Staffing metrics  MDS accuracy affecting publicly reported measures Collaborate with facility leadership to improve Five-Star performance.

Education

& Training Develop and provide education on:  CMS RAI Manual updates  PDPM  Section GG  Section K  Clinical documentation  ICD-10 coding  Medicare regulations  Medicaid updates  Managed Care requirements  Triple Check process  Quality Measures Provide orientation for new MDS Coordinators and ongoing competency validation.

Auditing Responsibilities Updated 10-17-23, 10-18-2023, 5.29.2025 Page 7 of 2 Conduct routine corporate audits of:  MDS completion  MDS accuracy  ARD scheduling  Medicare documentation  Medicaid case mix  Managed Care  Triple Check  Care Plans  CAAs  Skilled documentation  Diagnosis coding  Section GG  Section K  Therapy documentation  Physician documentation  PDPM optimization Issue written reports with corrective actions and follow-up plans.

Operational Support Assist facilities with:  Survey preparation  Mock surveys  Focused MDS reviews  Revenue recovery initiatives  New facility acquisitions  Facility transitions  Interim MDS coverage  Regulatory compliance initiatives Reporting Responsibilities Prepare and present monthly corporate reports including: Updated 10-17-23, 10-18-2023, 5.

29.2025 Page 8 of 2  MDS completion compliance  Transmission compliance  PDPM reimbursement trends  Medicare census  Medicaid Case Mix  Managed Care census  Five-Star trends  Quality Measures  Triple Check compliance  Revenue opportunities  Audit findings  Facility scorecards