Medicare/ Medicaid Reimbursement Specialist

OverviewWe are seeking a dedicated and detail-oriented Medicare/Medicaid Reimbursement Specialist to join our healthcare administration team.The ideal candidate will possess a comprehensive understanding of medical billing and coding procedures, with particular expertise in Medicare and Medicaid reimbursement processes.The Medicare/Medicaid Reimbursement Specialist is responsible for ensuring accurate and compliant billing, coding, and reimbursement processes for skilled nursing services.This role supports optimal revenue cycle performance by validating clinical documentation, educating staff on regulatory requirements, and assisting with admissions and insurance authorization processes.The position works collaboratively with nursing, therapy, admissions, and finance teams to maximize reimbursement while maintaining compliance with CMS and state guidelines.Key Responsibilities Reimbursement & Billing Oversight Ensure accurate billing for Medicare Part A, Medicare Advantage, Medicaid, and other payers in accordance with CMS and state regulations Review and validate MDS data, ICD-10 coding, and PDPM components to ensure proper reimbursement Monitor case mix index (CMI) and reimbursement trends; identify opportunities for optimization Audit claims prior to submission to reduce denials and ensure compliance Collaborate with the business office to resolve billing discrepancies and denied claims.Documentation & Compliance Conduct routine clinical documentation audits to ensure accuracy, completeness, and regulatory compliance Ensure documentation supports skilled level of care, services billed, and reimbursement levels Maintain knowledge of CMS guidelines, F-tags, and state-specific Medicaid reimbursement rules Assist with survey readiness related to documentation and reimbursement processes Staff Education & Training Provide ongoing education to nursing, therapy, and interdisciplinary teams on:Skilled documentation requirements PDPM and reimbursement drivers Medicare and Medicaid coverage criteria Develop tools, cheat sheets, and in-services to improve documentation quality and consistency Provide real-time feedback and coaching to staff based on audit findings Admissions & Authorization Support Serve as backup support for admissions processes as needed Review referral documentation to ensure clinical and financial appropriateness for admission Assist with verification of benefits and payer source identification Support and/or complete insurance authorizations for skilled services, including submitting clinical updates for continued stay reviews Communicate with payers to secure approvals and prevent authorization lapses Interdisciplinary Collaboration Participate in Medicare meetings, triple check meetings, and care plan discussions Partner with therapy, nursing leadership, and admissions to align clinical care with reimbursement requirements Provide recommendations to improve census mix and reimbursement outcomes Qualifications Associate's or Bachelor's degree in Healthcare Administration, Nursing, or related field preferred Minimum of 2-3 years of experience in SNF reimbursement, MDS, billing, or case management Strong knowledge of:Medicare Part A and Medicaid reimbursement PDPM methodology ICD-10 coding CMS regulations and documentation requirements Experience with EMR systems and billing software Skills & Competencies Strong analytical and auditing skills In-depth understanding of skilled documentation requirements Ability to educate and influence clinical staff Detail-oriented with strong organizational skills Effective communication and collaboration across departments Ability to manage multiple priorities in a fast-paced environment Preferred Qualifications MDS Coordinator experience or RAC-CT certification Experience with Medicare Advantage plans and authorization processes Prior experience in a skilled nursing facility (SNF) setting Work Environment Primarily office-based within a skilled nursing facility.Regular interaction with clinical staff, residents, and families May require occasional on-call or weekend support for admissions/authorizations Pay:$100,000.00 per year Benefits:Dental insurance Health insurance Life insurance Paid time off Professional development assistance Retirement plan Tuition reimbursement Vision insurance Work Location:Hybrid remote in Wilmington, DE 19806.