Director of Reimbursement

Director of Reimbursement

Status: Full-Time

Location: 25115 SW Parkway Ave. Wilsonville, OR (Hybrid)

Compensation: $140,000.00 - $160,000.00

Employee Perks:

• Tuition assistance
• Mentorship opportunities
• Employee assistance program featuring free counseling services, financial coaching, legal services, and more
• Generous employee referral program
• Paid time off/sick leave (rolls over annually)
• 401K retirement plan with employer contributions
• Comprehensive benefits package with medical coverage, voluntary dental, vision, and life insurance, short-term disability, and AD&D coverage

Avamere understands the importance of affordable and accessible healthcare for our team members and is very excited to partner with SEIU 503 and the Essential Worker Healthcare Trust to offer an excellent health insurance benefit plan at a significantly reduced cost to the employee.

Starting in 2023, our Full-Time Oregon team members will be able to participate in a PPO or HMO plan with deductibles as low as $800.00 with significantly reduced premium costs. Employees will be eligible to start using their benefits within their first month of hire – no 60+ day waiting period! Vision, Dental, STD, LTD, AD&D, and other benefits are available for enrollment as well.

The Director of Clinical Reimbursement is responsible for ongoing review and management of clinical service revenue streams. The Director establishes and maintains an in-depth understanding of all clinical programs that impact reimbursement. Strategically and collaboratively, the Director develops structures to maximize clinical services revenue streams in accordance with all rules and regulations that apply to the business of Avamere Living.

The Director of Clinical Reimbursement reports to the Vice President of Clinical Services.

Duties & Responsibilities:

Administrative Functions

• Collaborates with Operations/designee to establish MDS (Minimum Data Set) directors’ annual goals and performance evaluations.
• Internal expert on Medicaid and Medicare case mix processes, PDPM, CMI, CMAO, categories, and other clinical reimbursement opportunities.
• As the subject matter expert, maintains continuous learning and working knowledge of key reimbursement regulations and policies that impact business. Shares industry standards with leadership teams.
• Collaborates with corporate and divisional management teams to respond strategically to reimbursement opportunities.
• Translates regulatory and policy developments into meaningful guidance to internal processes.
• Establish metrics and goals for process and outcome measures that affect and result in successful reimbursement.
• Develops and maintains an organizational structure for review and audit of clinical reimbursement methodologies and outcomes including, but not limited to, trends in reimbursement and payer denial rates and relationships to clinical documentation; implements improvement strategies as indicated.
• Establishes ongoing evaluation of relationships with payers and consultants that impact successful reimbursement.
• Ensures dissemination of appropriate information to staff through meetings at all divisions of the organization, including educational sessions on the impact of clinical care processes and documentation on reimbursement.
• Ensures compliance with all applicable regulations and Code of Business Ethics.
• Oversees the Regional Reimbursement nurses and assignments, including RAC Auditors.

Personnel Functions

• Develop and maintain a good rapport with interdepartmental personnel, as well as other departments within the facility to ensure that services can be maintained to meet the needs of the residents.
• Make appropriate reports to department supervisors as required or as may be necessary. Follow Avamere’s established procedures.
• Report known or suspected incidents of fraud, waste, and or abuse.
• Participation in all compliance training programs.
• and managed care residents as required.

Budget and Planning Functions

• Report suspected or known incidence of fraud relative to false billings, cost reports, kickbacks, etc.

Residential Rights

• Maintain the confidentiality of all resident care information including protected health information. Report known or suspected incidents of unauthorized disclosure of such information.
• Review complaints and grievances made by the resident and make a written/oral report to the Nursing Manager indicating what action(s) were taken to resolve the complaint or grievance. Follow the facility’s established procedures.
• Report all allegations of resident abuse and/or misappropriation of resident property.

Requirements & Qualifications:

• Must have, as a minimum, five (5) years of experience in a regional nurse/Director Reimbursement/MDS role.
• Must have training in rehabilitative and restorative nursing practices.
• Must have a working knowledge of managed care rules, regulations, and guidelines.
• Must have a current, unencumbered, active license to practice as an RN or LPN (Licensed Practical Nurse) in Washington or Oregon state. Must have both licenses within 6 months.
• Must be knowledgeable of nursing and medical practices and procedures, as well as laws, regulations, and guidelines that pertain to managed care and nursing care facilities.
• Must be willing to seek out new methods and principles and be willing to incorporate them into existing nursing practices.

Avamere Living is an Equal Opportunity Employer and participates in E-Verify.