Training Specialist, Medical Review Audit – Clinical RN

Machinify is a leading healthcare intelligence company with expertise across the payment continuum, delivering unmatched value, transparency, and efficiency to health plan clients across the country. Deployed by over 85 health plans, including many of the top 20, and representing more than 270 million lives, Machinify brings together a fully configurable and content-rich, AI-powered platform along with best-in-class expertise. We’re constantly reimagining what’s possible in our industry, creating disruptively simple, powerfully clear ways to maximize financial outcomes and drive down healthcare costs. 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. 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