Training Specialist, Medical Review Audit - Clinical RN

Key Responsibilities to include:

Training Program Design & Development

• Design, build, and maintain comprehensive training curricula for clinical audit nurses and audit associates covering IPF and IRF claim review, documentation requirements, medical necessity criteria, coding, and payer policy.
• Develop structured training programs, job aids, reference materials, and assessment tools for new hire onboarding, ongoing competency, performance improvement, and new program implementations.
• Translate complex clinical, regulatory, and payer-specific requirements into clear, audit-ready training content appropriate for the intended audience — including IPF PPS , IRF PPS , DSM-5 diagnostic criteria, level of care distinctions, and facility-specific billing rules.
• Maintain and update training materials on a continuous basis to reflect changes in CMS payment rules , LCD/NCD policy , coding guidelines, and client-specific requirements affecting IPF and IRF audits.
• Build and manage training content within the Learning Management System (LMS) ; ensure materials are current, accessible, and structured for effective delivery in a remote environment.

Training Delivery & Outcomes

• Plan, coordinate, and deliver new hire training and ongoing education across 1:1, small group, and virtual classroom formats.
• Track and report training completion, assessment scores, and post-training performance metrics ( audit accuracy , QA results , appeals outcomes ); use data to evaluate program effectiveness and drive continuous improvement.
• Identify training gaps through QA results , audit performance data, appeals trends, and direct observation; develop and execute targeted remediation plans.
• Conduct User Acceptance Testing on new audit platform workflows and reporting enhancements; incorporate findings into training materials before go-live.
• Deliver training on new client implementations, new audit programs, and updated audit concepts in coordination with operations and management.

Clinical Subject Matter Expertise

• Serve as the primary subject matter authority for IPF audit training , including: inpatient psychiatric medical necessity criteria (vs. PHP and IOP level of care), qualifying DSM-5 diagnoses, physician certification and attestation requirements, daily progress note standards, treatment plan documentation, safety and risk assessment requirements, and ECT add-on billing under IPF PPS .
• Serve as the primary subject matter authority for IRF audit training , including: the 60%/75% compliance rule and qualifying conditions, pre-admission screening, post-admission physician evaluation timelines, IRF-PAI completion requirements, 3-hour therapy rule documentation (including exceptions), weekly interdisciplinary team conference requirements, individualized plan of care standards, and CMG assignment logic .
• Maintain current, working knowledge of IPF PPS and IRF PPS payment rules, ICD-10-CM/PCS coding applicable to inpatient psychiatric and rehabilitation claims, DRG and CMG assignment , and mental health parity compliance requirements.
• Monitor changes to CMS regulations , LCD/NCD coverage criteria , coding guidelines, and clinical standards; proactively update training content and communicate changes to audit staff.
• Provide consultative input on audit platform requirements, workflow design, and business rule development as they relate to IPF and IRF audit processes.

Collaboration & Program Support

• Partner with operations management, QA , and compliance to align training programs with business objectives and client contractual requirements.
• Support management in documenting workflows and process improvement plans; contribute to training-related components of new concept implementation.
• Provide input on training scheduling to ensure delivery meets operational timelines, legal requirements, and contractual obligations.

Knowledge, Skills, and Abilities

• Deep working knowledge of IPF payment and documentation requirements: IPF PPS , qualifying psychiatric diagnoses and DSM-5 criteria, medical necessity standards for inpatient psychiatric care, physician certification requirements, treatment plan and daily progress note standards, safety assessment documentation, and ECT add-on billing .
• Strong command of IRF coverage and documentation requirements: IRF PPS , qualifying conditions under the 60%/75% compliance rule , pre-admission screening, IRF-PAI completion timelines, 3-hour therapy rule and exceptions, interdisciplinary team conference documentation, FIM scoring context, and CMG assignment .
• Ability to distinguish and articulate medical necessity criteria across levels of care: inpatient psychiatric vs. PHP/IOP ; IRF vs. SNF — and train auditors to apply those distinctions accurately and consistently.
• Proficiency with ICD-10-CM/PCS coding for inpatient psychiatric and rehabilitation claims; working knowledge of DRG and CMG assignment logic .
• Demonstrated ability to design and deliver adult learning programs that produce measurable, documented outcomes in a clinical or healthcare audit production environment.
• Proficiency with instructional design principles, needs assessment methodology, and learning evaluation frameworks (e.g., Kirkpatrick model ).
• Experience developing and managing training content in a Learning Management System (LMS) .
• Strong data interpretation skills; able to analyze QA results , audit accuracy metrics , and appeals data to assess training effectiveness and identify gaps.
• Familiarity with utilization management tools such as MCG or InterQual , particularly criteria applicable to inpatient psychiatric and rehabilitation level of care determinations.
• Proficient in Microsoft Office Suite (intermediate to advanced PowerPoint , Word , and Excel ); experience with curriculum development or e-learning authoring tools preferred.
• Clear, precise communicator who can translate technical clinical and billing content for audiences with varying levels of experience.

Required Qualifications

• Active, unrestricted nursing license in good standing; not sanctioned or excluded from the Medicare program by OIG .
• AHIMA or AAPC coding certification required ( CPC , CCS , CCS-P , RHIT , or equivalent).
• Bachelor’s degree in Nursing, Health Information Management, Education, or a related field required.
• 3+ years of direct experience performing medical record audits in IPF and/or IRF claims in a payer or similar audit organization is required ; experience across both segments strongly preferred.
• Direct clinical experience in an inpatient psychiatric or inpatient rehabilitation setting required; this experience must be reflected in the candidate’s nursing background, not only their audit history.
• 3+ years of experience developing and delivering clinical or healthcare training programs with documented, measurable outcomes ; remote learning delivery required.
• Demonstrated experience identifying training gaps from performance data and implementing remediation programs with evidence of improvement.

Preferred Qualifications

• Master’s degree in Nursing, Education, Health Informatics, or a related field.
• Clinical background in inpatient psychiatric nursing, including familiarity with psychiatric assessment tools ( PHQ-9 , Columbia Suicide Severity Rating Scale , etc.), treatment planning, and level of care criteria.
• Clinical background in inpatient rehabilitation nursing, including familiarity with FIM scoring , functional goal-setting, and IRF care coordination .
• Experience with mental health parity compliance review or behavioral health utilization management in a payer or audit context.
• Prior experience in a RAC , MAC , TRICARE , or commercial payer audit environment focused on inpatient facility claims.
• Experience conducting User Acceptance Testing on audit platform or reporting system enhancements.
• Experience contributing to provider education, audit edit development, or medical policy improvement for IPF or IRF programs.