Training Specialist, Medical Review Audit – Clinical RN

Accountabilities:

• • Design, develop, and maintain comprehensive training curricula for clinical audit nurses and associates covering post-acute claims review, documentation, medical necessity, coding, and payer policies.
  • Create structured onboarding, continuing education, competency, remediation, and implementation programs, supported by job aids, reference materials, assessments, and other learning resources.
  • Translate complex clinical and regulatory requirements into clear training content covering areas such as IPF PPS, IRF PPS, DSM-5 diagnostic criteria, level-of-care distinctions, facility billing rules, and related audit concepts.
  • Maintain training content in the Learning Management System (LMS), ensuring materials remain accurate, accessible, and effective for remote delivery.
  • Deliver training through virtual classrooms, small-group sessions, and one-to-one formats while adapting delivery to different experience levels.
  • Track training completion, assessment results, audit accuracy, QA outcomes, appeals trends, and other performance indicators to measure program effectiveness.
  • Identify knowledge and performance gaps through audit data, quality results, appeals, and observation, then design and implement targeted remediation plans.
  • Conduct User Acceptance Testing for new audit platform workflows and reporting enhancements and incorporate relevant findings into training programs before launch.
  • Serve as a clinical subject matter expert for IPF and IRF audit requirements, including medical necessity, documentation, payment rules, coding, and level-of-care determinations.
  • Train auditors on IPF requirements such as qualifying psychiatric diagnoses, physician certification and attestation, treatment plans, daily progress notes, safety assessments, and ECT add-on billing.
  • Train auditors on IRF requirements including the 60%/75% compliance rule, pre-admission screening, IRF-PAI timelines, the 3-hour therapy rule and exceptions, interdisciplinary team conferences, individualized care plans, and CMG assignment.
  • Monitor changes to CMS regulations, LCD/NCD criteria, coding guidelines, and clinical standards and proactively update training materials and communicate changes.
  • Partner with operations, QA, compliance, and management to align training with business objectives, client requirements, workflows, and implementation timelines.
  • Provide consultative input into audit platform requirements, workflow design, business rules, process improvements, and medical review initiatives.

  Requirements

  • Active, unrestricted nursing license in good standing, with no Medicare program sanction or exclusion by OIG.
  • Bachelor’s degree in Nursing, Health Information Management, Education, or a related field, or equivalent relevant qualifications.
  • At least 3 years of direct experience performing medical record audits involving post-acute claims, with specific experience in IPF and/or IRF required; experience across Home Health and DME is strongly preferred.
  • At least 3 years of experience developing and delivering clinical or healthcare training programs with measurable outcomes, including experience delivering training remotely.
  • Deep working knowledge of IPF PPS, psychiatric medical necessity criteria, qualifying DSM-5 diagnoses, physician certification, treatment planning, daily progress documentation, safety assessments, and ECT billing.
  • Strong knowledge of IRF PPS, the 60%/75% compliance rule, qualifying conditions, pre-admission screening, IRF-PAI requirements, therapy documentation, interdisciplinary team requirements, functional scoring concepts, and CMG assignment.
  • Ability to distinguish medical necessity and level-of-care criteria across inpatient psychiatric care versus PHP/IOP and IRF versus SNF settings.
  • Proficiency with ICD-10-CM/PCS coding for inpatient psychiatric and rehabilitation claims, with working knowledge of DRG and CMG assignment logic.
  • Demonstrated expertise in instructional design, needs assessment, adult learning methodologies, and learning evaluation frameworks such as the Kirkpatrick model.
  • Strong analytical skills and the ability to use QA results, audit accuracy metrics, appeals data, and operational performance information to identify training opportunities.
  • Experience managing learning content through an LMS and proficiency with Microsoft Office, particularly PowerPoint, Word, and Excel.
  • Familiarity with utilization management tools such as MCG or InterQual is valuable.
  • Strong written and verbal communication skills, with the ability to explain complex clinical, regulatory, and billing concepts to audiences with varying levels of experience.
  • Strong organizational, project management, and collaboration skills, with the ability to manage multiple training initiatives and priorities.
  • Ability to work effectively with clinical, operational, compliance, and business stakeholders and translate requirements into practical learning solutions.
  • Preferred qualifications include a master’s degree, AHIMA or AAPC certification such as CPC, CCS, CCS-P, or RHIT, and direct clinical experience in inpatient psychiatric or rehabilitation settings.
  • Additional valuable experience includes mental health parity reviews, behavioral health utilization management, RAC/MAC/TRICARE or commercial payer audit environments, audit platform testing, provider education, audit edit development, or medical policy improvement.

  Benefits

  • Opportunity to make a measurable impact on healthcare quality, audit accuracy, and financial outcomes.
  • Specialized role combining clinical nursing expertise, healthcare auditing, and professional training.
  • Collaborative environment working with operations, QA, compliance, and other healthcare professionals.
  • Opportunities to contribute to new programs, platform improvements, process enhancements, and innovative audit initiatives.
  • Remote learning and collaboration environment.
  • Supportive workplace committed to equal employment opportunity and an inclusive employee experience.
  • Reasonable accommodations available throughout the recruitment and employment process, where applicable.