Clinical Reimbursement Consultant RN

PruittHealth; Savannah (GA); On-site; USD 90,000 - 120,000; Full time

Job summary

PruittHealth in Savannah, GA seeks an experienced Case Mix Director / MDS Nurse to lead RAI processes, care management, and related software usage to ensure appropriate resident care and timely reimbursement. The role requires managing case mix, PPS and compliance across facilities, with oversight of MDS accuracy and staff education.

Responsibilities include data distribution, education of center partners, policy adherence, and PI participation.

Qualifications

• Knowledge of state and federal regulations related to RAI and reimbursement.
• RN license active in the state of residence.
• Bachelor's degree in Nursing or Allied Health required.

Responsibilities

• Distribute current and revised RAI/PPS/Case Mix information to partners promptly.
• Provide status updates on clinical and financial reimbursement to regional and corporate staff.
• Participate in professional organizations to strengthen RAI/process knowledge.
• Educate center partners on RAI, Care Plan, PPS and Case Mix processes and their impact.
• Instruct on reading and using various state, federal, and company reports.
• Offer consultation to ensure MDS accuracy and policy compliance.
• Identify trends and drive PI plans via analysis of reports.
• Maintain knowledge of clinical software, billing systems, and support resources.
• Interview applicants for CMDs/MDS Nurse and advise hiring authority.
• Oversee orientation process for new CMDs.
• Adhere to privacy guidelines for residents' PHI.
• Participate in PI activities; frequent overnight travel may be required.

Skills

Regulatory knowledge

RN license active

Nurse Assessment Coordinator preferred

Microsoft proficiency

Education

Bachelor's degree in Nursing or Allied Health

Tools

MatrixCare

Pointright

Microsoft

Job description

JOB PURPOSE

• The RAI Process, the Care Management Process, and the use of various supporting software applications to ensure an appropriate level of Resident care and equitable and timely reimbursement of the care provided.
• Utilization of skilled Medicare services
• Medicare RUG, Medicaid Case Mix CMI / or Skilled Level of Care management

JOB PURPOSE

• The RAI Process, the Care Management Process, and the use of various supporting software applications to ensure an appropriate level of Resident care and equitable and timely reimbursement of the care provided.
• Utilization of skilled Medicare services
• Medicare RUG, Medicaid Case Mix CMI / or Skilled Level of Care management

KEY RESPONSIBILITIES

• Ensures current, new, and revised RAI / PPS / Case Mix information is distributed to appropriate partners in a timely manner.
• Provides information to regional and corporate staff on the status of clinical and financial reimbursement.
• Participates in national and state professional organizations that strengthen the company’s position and knowledge of the RAI process, Case Mix and clinical software programs.
• Provides information and education to center partners on the importance and use of the RAI and Care Plan, Medicare PPS, and State Case Mix and Skilled Level of Care processes and their correlation to resident care and reimbursement.
• Provides instruction on how to read, interpret and use the information contained in various state, federal, and company initiated and generated reports.
• Provides expertise, consultation and guidance to appropriate partners to ensure MDS accuracy and adherence to company policy and procedures, as well as state and federal regulations and guidelines based on information derived from audits and other available data.
• Identifies trends and areas of improvement and ensures an appropriate PI plan is completed, through analysis of financial and clinical reports.
• Maintains in-depth knowledge of the clinical software and billing system, the RAI process, and company initiated online support to help investigate and troubleshoot user-related software issues.
• Interviews applicants for the Case Mix Director / MDS Nurse and provides recommendations to the hiring authority.
• Oversees and coordinates the process for a thorough and timely orientation for new CMDs.
• Adheres to and oversees communication of privacy guidelines relative to the confidentiality of residents’ protected health information.
• Participates in PI activities as appropriate
• Frequent overnight travel may be required.

KNOWLEDGE, SKILLS, ABILITIES

• Knowledge of state and federal regulations, both clinical and financial as it relates to the RAI process and reimbursement systems.
• Current Licensed Registered Nurse or Allied Health Care Professional in state of residence. Credential Nurse Assessment Coordinator preferred.
• Microsoft required
• Experience in MatrixCare, Pointright a plus

MINIMUM EDUCATION REQUIRED

Bachelors’ degree from an accredited school of Nursing or other Allied Health Care Institution

MINIMUM EXPERIENCE REQUIRED

Five- (5) years health care management, MDS Assessment & care Planning experience in multi-facility, long-term care organizations preferred.

Three (3) years clinical responsibility and experience with RAI process (MDS) required

MINIMUM LICENSURE/CERTIFICATION REQUIRED BY LAW

Current, active license as a Registered Nurse or Allied Health Professional in the State practicing.

ADDITIONAL QUALIFICATIONS

(Preferred qualifications)

Software: MatrixCare and/or Pointright

Family Makes Us Stronger. Our family, your family, one family. Committed to loving, giving, and caring. United in making a difference.

As an Equal Employment Opportunity employer, all qualified applicants will receive consideration without regard to race, color, religion, sex, national origin, disability, or veteran status.

For Florida Job Postings Only

For more information regarding Florida’s Care Provider Background Screening Clearinghouse Education and Awareness, please visit https://info.flclearinghouse.com

KNOWLEDGE, SKILLS, ABILITIES

• Knowledge of state and federal regulations, both clinical and financial as it relates to the RAI process and reimbursement systems.
• Current Licensed Registered Nurse or Allied Health Care Professional in state of residence. Credential Nurse Assessment Coordinator preferred.
• Microsoft required
• Experience in MatrixCare, Pointright a plus

Job

Administrative

Primary Location

Georgia-Savannah

Other Locations

• Florida-Jacksonville
• Florida-Tallahassee

Schedule

Full-time

Shift

1st Shift

Job Posting

Nov 2, 2026, 1:03:25 PM

Work Locations

PruittHealth - Savannah