Regional Clinical Reimbursement Program Specialist

General Purpose

This role exists to improve the care our residents receive and make sure that care is accurately reflected in the Florida Medicaid Quality Incentive Program (QIP). The QIP measures what matters to residents and families: fewer falls and pressure injuries, fewer infections and hospital transfers, less reliance on psychotropic medications, preserved independence, and stable nursing teams. When care improves and is documented accurately, the points follow.

The specialist is accountable for making sure every facility's QIP score accurately reflects the quality of care delivered, across all 16 measures and all 49 available points. That means driving real clinical improvement, accurate documentation, clean data, and on-time submissions, so no facility loses recognition it has earned. All coding and documentation must accurately reflect each resident's condition; this role never adjusts documentation to influence quality scores or reimbursement.

Essential Duties

Resident-Centered Clinical Improvement

•       Partner with DONs, Medical Directors, and consultant pharmacists on clinically appropriate psychotropic stewardship, including gradual dose reductions where indicated, behavioral care planning, and non-pharmacologic dementia approaches.

•       Lead falls-with-injury, pressure injury, and infection-prevention programs (catheter stewardship, hand hygiene, antibiotic stewardship, early UTI recognition and treatment).

•       Strengthen restorative nursing, continence programs, and mobility plans so residents keep their independence and ADL function.

•       Reduce avoidable hospitalizations through early change-of-condition recognition (INTERACT or equivalent), physician communication, and family engagement, without delaying medically necessary transfers.

•       Drive influenza vaccination by making sure every resident is offered the vaccine, receives education, and has their status documented, and support restraint-free care.

•       Run QAPI performance improvement projects with measurable goals, and give each care team resident-level reports with specific clinical next steps.

•       Round on units regularly to observe care, coach staff, and confirm that care plans match what happens at the bedside.

Staffing and Structure Points (6 points)

•       Own each facility's position on both staffing measures and drive it to the next percentile. For October 2026 those cutoffs were 3.54 / 3.78 / 4.19 combined direct-care hours per patient day and 0.127 / 0.185 / 0.235 for the activities/social work ratio (50th / 75th / 90th percentile).

•       Work with HR and nursing leaders on RN retention, onboarding, and competency, since consistent caregivers drive outcomes and RN turnover is itself a scored measure.

•       Validate PBJ submissions and cost report staffing hours with payroll and finance so every direct-care hour is captured.

Accurate Measurement

•       Audit MDS coding for accuracy in both directions, with no overcoding and no undercoding, so reported quality reflects actual care and every diagnosis and exclusion is supported in the clinical record.

•       Review CASPER/QM reports monthly, and complete a full pre-snapshot data accuracy review before May 31.

•       Ensure full compliance with the RAI Manual, CMS and AHCA rules, and company compliance policy, and escalate any documentation concern to the compliance department.

QIP Strategy and Credentialing

•       Maintain a facility-level scorecard across all 16 measures showing current points, projected points, and the gap to the next cutoff, and set a quarterly point plan with each Administrator and DON.

•       Target near-miss measures and every measure eligible for the 0.5-point, 20% year-over-year improvement credit.

•       Own the credentialing roadmap for each facility: Five-Star overall rating, Joint Commission accreditation, AHCA/NCAL National Quality Award, and Florida Gold Seal.

•       Track AHCA rule changes and the 2027 rebase, and support Medicare PDPM and managed care MDS accuracy.

KEY PERFORMANCE INDICATORS

•       Measurable improvement in resident outcomes: falls with injury, pressure injuries, infections, appropriate psychotropic use, avoidable hospitalizations, and ADL function.

•       An annual QIP improvement goal for each facility, with every facility above the qualifying threshold and working toward its peer-group median.

•       Influenza vaccination offered to and documented for every eligible resident.

•       Staffing measures moved up at least one percentile tier where below the 90th.

•       MDS audit accuracy (both directions) and on-time, accurate data submissions.

QUALIFICATIONS

Required

Active Florida RN license; 3+ years of multi-facility MDS/clinical reimbursement experience; expert knowledge of the RAI Manual, CMS QMs, and Five-Star; working knowledge of Florida Medicaid PPS and QIP scoring; strong Excel/data skills; ability to influence without direct authority.

Preferred:

RAC-CT/RAC-CTA; QAPI leadership with measurable QM gains; Joint Commission or Quality Award experience; PointClickCare proficiency.

Physical Demands

•       Ability to sit for extended periods while performing data analysis, documentation reviews, reporting, and administrative duties.

•       Ability to stand and walk regularly throughout healthcare facilities to conduct clinical rounds and observe resident care.

•       Ability to travel between assigned facilities for meetings, audits, training, and program oversight.

•       Ability to use a computer, telephone, and other office equipment for extended periods.

•       Ability to occasionally bend, reach, and lift or carry light materials while conducting facility visits and clinical reviews.

We are an equal opportunity employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, age, disability, protected veteran status, or any other legally protected status.