Clinical Reimbursement Consultant

About the role

PACS Group is a leading post-acute healthcare holding company operating skilled nursing, senior living, and related care facilities across multiple states. We are committed to clinical excellence, operational integrity, and sustainable growth across our portfolio.

The Clinical Reimbursement Consultant partners with facility clinical and business office teams to ensure accurate, compliant, and optimized reimbursement under Medicare, Medicaid, and managed care programs. This role provides hands-on guidance on MDS accuracy, PDPM/case-mix optimization, and documentation practices that support appropriate reimbursement and regulatory compliance.

Responsibilities

• Conduct on-site and remote reviews of MDS assessments for accuracy, timeliness, and PDPM classification integrity
• Partner with facility MDS coordinators, DONs, and interdisciplinary teams to strengthen documentation supporting skilled level of care and case-mix indices
• Monitor and analyze facility-level reimbursement data (PDPM, RUG scores, Medicaid case-mix) to identify trends, risks, and opportunities
• Provide education and training to facility teams on MDS coding, look-back periods, and regulatory updates (CMS, state Medicaid)
• Support triple-check processes and pre-billing reviews to reduce claim denials and payment errors
• Conduct mock audits and prepare facilities for state/federal surveys and RAC/UPIC audits
• Track and report key reimbursement metrics (case-mix index, ADR trends, denial rates) to regional and corporate leadership
• Stay current on PDPM, Medicaid case-mix, and managed care reimbursement methodology changes across operating states
• Collaborate with billing/AR teams to resolve reimbursement-related claim issues

Qualifications

Required: RN, LPN, or equivalent clinical license (or RAC-CT certification strongly preferred); 3+ years of MDS coordination or clinical reimbursement experience in skilled nursing/post-acute setting; Strong working knowledge of PDPM, RUG-IV, and state Medicaid case-mix systems; Experience with MDS software (PointClickCare, MatrixCare, or similar); Ability to travel to facilities within assigned region.

Preferred: RAC-CT (Resident Assessment Coordinator Certified); Multi-facility or regional consulting experience; Experience supporting survey readiness and audit response.

Skills

• Strong analytical skills with ability to translate data into actionable recommendations
• Clear, confident communicator across clinical and business office stakeholders
• Comfortable operating with autonomy across a multi-site portfolio
• High attention to regulatory detail and documentation standards

Benefits

• Health Coverage: medical, dental, and vision plans
• PTO and Vacation: generous paid time off and holidays
• Financial Wellness: Health Savings Accounts (HSA) and Flexible Spending Accounts (FSA)
• Retirement Planning: 401(k) plan with company contributions
• Support When You Need It: Employee Assistance Plan (EAP) for confidential support