Training Specialist, Medical Review Audit – Clinical RN in New York at Jobgether

This position is listed on behalf of a partner company, who manages all applications and next steps. Our partner is looking for a Training Specialist, Medical Review Audit – Clinical RN based in the United States.

This is a specialized clinical training role focused on strengthening the quality and consistency 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.
The role has a strong focus on Inpatient Psychiatric Facility (IPF) and Inpatient Rehabilitation Facility (IRF) claims, with additional exposure to Home Health and DME.
You will translate complex clinical, regulatory, coding, and payment requirements into practical, audit-ready learning experiences.
Your work will directly influence auditor accuracy, productivity, quality outcomes, and the effectiveness of new program implementations.
Working closely with operations, QA, compliance, and other stakeholders, you will identify knowledge gaps and build targeted improvement programs.
This opportunity is ideal for an experienced RN and healthcare audit professional who enjoys combining clinical subject matter expertise with measurable training outcomes

• 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.

• 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.

• 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.