The Training Specialist, Medical Review Audit - Clinical RN owns the design, development, and delivery of training programs for clinical audit staff specializing in Inpatient Psychiatric Facility (IPF) and Inpatient Rehabilitation Facility (IRF) claims. This is not a generalist training role. The right candidate brings deep, working knowledge of IPF and IRF documentation standards, payment systems, and medical necessity criteria alongside a demonstrated track record of building training programs that produce measurable improvements in auditor accuracy, productivity, and quality outcomes. This role requires an active nurse who can function as both a clinical subject matter expert and a skilled adult learning practitioner.
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.
