Training Specialist – Medical Review Audit, Clinical RN

This is a fully remote position, open to applicants in United States.

📋 Description

• Create, develop, and sustain extensive training programs for clinical audit nurses and audit associates that encompass IPF and IRF claim reviews, documentation, medical necessity, coding, and payer policy.

• Design onboarding, competency, performance enhancement, and program implementation training, which includes job aids, reference materials, and assessments.

• Simplify intricate clinical, regulatory, and payer-specific requirements into straightforward, audit-ready training materials.

• Update training resources to align with CMS regulations, LCD/NCD policies, coding guidelines, and requirements specific to clients.

• Construct and oversee training content within the LMS for efficient remote distribution.

• Organize, coordinate, and provide education for new hires and ongoing training through individual, small group, and virtual classroom formats.

• Monitor training completion rates, assessment results, audit accuracy, QA outcomes, and appeal results; leverage data to enhance training programs.

• Recognize training deficiencies and implement focused remediation strategies.

• Perform User Acceptance Testing on audit platform workflows and reporting updates.

• Provide training for client implementations, audit programs, and new audit concepts.

• Act as the main subject matter expert for IPF and IRF audit training.

• Keep track of CMS regulations, coverage criteria, coding standards, and clinical benchmarks; update materials and communicate any changes.

• Contribute to the requirements of the audit platform, workflow design, and business rules.

• Collaborate with operations management, QA, and compliance to ensure training aligns with business and client needs.

• Assist in documenting workflows, process improvement strategies, and the implementation of new concepts.

• Offer insights on training timelines to adhere to operational, legal, and contractual obligations.

⛳️ Requirements

• Current, unrestricted nursing license in good standing; not sanctioned or excluded from the Medicare program by OIG.

• AHIMA or AAPC coding certification is required (CPC, CCS, CCS-P, RHIT, or equivalent).

• A bachelor’s degree in Nursing, Health Information Management, Education, or a related field is mandatory.

• Over 3 years of direct experience in conducting medical record audits for IPF and/or IRF claims within a payer or similar auditing organization is required.

• Direct clinical experience in an inpatient psychiatric or rehabilitation setting is necessary.

• More than 3 years of experience in developing and delivering clinical or healthcare training programs with documented, measurable results; experience in remote learning delivery is essential.

• Proven experience in identifying training needs from performance data and executing remediation plans that demonstrate improvement.

• Extensive knowledge of IPF PPS, DSM-5 criteria, medical necessity standards, physician certification, treatment plan and daily progress note standards, safety assessment documentation, and ECT add-on billing.

• Strong understanding of IRF PPS, the 60%/75% compliance requirement, pre-admission screening, IRF-PAI timelines, the 3-hour therapy rule, interdisciplinary team meetings, FIM scoring context, and CMG assignment.

• Proficiency in ICD-10-CM/PCS coding, DRG and CMG assignment logic, instructional design, LMS platforms, data analysis, Microsoft Office Suite, and adult learning evaluation frameworks.

• Familiarity with MCG or InterQual utilization management tools.

• Experience with curriculum development or e-learning authoring tools is preferred.

• A master’s degree in Nursing, Education, Health Informatics, or a related field is preferred.

🏝️ Benefits

• Equal employment opportunity.

• Employment at will.

• Participation in E-Verify as required by applicable law.

• Reasonable accommodations during the application or recruitment process.