Training Specialist, Medical Review Audit – Clinical RN

The Training Specialist, Medical Review Audit – Clinical RN is responsible for designing and delivering comprehensive training curricula for clinical audit professionals. This role focuses on strengthening the quality and consistency of post-acute medical claims auditing.

About the role

This is a specialized clinical training role focused on enhancing the accuracy and productivity of post-acute medical claims auditing. You will combine hands-on nursing expertise with adult learning and instructional design to develop training for clinical audit professionals.

Responsibilities

• Create and maintain comprehensive training curricula for clinical audit nurses and associates covering post-acute claims review, documentation, medical necessity, coding, and payer policies.
• Develop 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.
• 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.
• 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

• A master’s degree.
• AHIMA or AAPC certification such as CPC, CCS, CCS-P, or RHIT.
• 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.