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
• Training Delivery & Outcomes
• Clinical Subject Matter Expertise
• Collaboration & Program Support

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.

Equal Employment Opportunity at Machinify

We are committed to equal employment opportunity regardless of race, color, ancestry, religion, sex, national origin, sexual orientation, age, citizenship, marital status, disability, gender, gender identity or expression, or veteran status. We are proud to be an equal opportunity workplace. Machinify is an employment at will employer. We participate in E-Verify as required by applicable law. In accordance with applicable state laws, we do not inquire about salary history during the recruitment process. If you require a reasonable accommodation to complete any part of the application or recruitment process, please let our recruiters know. See our Candidate Privacy Notice at: https://www.machinify.com/candidate-privacy-notice/