Inpatient Rehabilitation SME - Remote Job Plymouth Minnesota USA,Healthcare

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The IRF CMG Coding & Payment Integrity SME is responsible for leading clinical and coding validation efforts related to CMS Inpatient Rehabilitation Facility (IRF) Prospective Payment System (PPS), with a specialized focus on Case Mix Group (CMG) assignment, functional scoring (IRF PAI), and comorbidity tiering accuracy.

This role partners across clinical, coding, and analytics teams to identify, validate, and recover payment variances driven by documentation gaps, functional scoring discrepancies, and incorrect comorbidity tier assignment.

You’ll enjoy the flexibility to work remotely
* from anywhere within the U.S. as you take on some tough challenges. For all hires in the Minneapolis or Washington, D.C. area, you will be required to work in the office a minimum of four days per week.

Primary Responsibilities:

CMG & Tiering Validation
- Perform detailed reviews of IRF cases to validate:
  - CMG assignment accuracy
  - Functional scoring (IRF PAI Section GG) integrity
  - Comorbidity tier assignment (Tier 1, 2, 3 vs. non-tier)
- Identify and quantify over payments and underpayments tied to CMG and tiering misclassification
- Apply CMS Grouper logic to validate expected CMG outcomes
Clinical Documentation & Coding Integrity
- Evaluate alignment between:
  - Medical record documentation
  - IRF PAI functional scores
  - ICD 10 coding and comorbidity capture
- Lead clinical validation for:
  - Etiologic diagnosis (primary rehab driver)
  - Comorbidity eligibility for tiering
- Identify patterns of:
  - Unsupported functional scores
  - Incorrect diagnosis sequencing
  - Missed or invalid tier opportunities
Audit & Recovery Strategy
- Support development of CMG-focused audit strategies, including:
  - Targeting high-weight CMGs
  - Tiering-driven opportunity identification
  - CARC/RARC mapping for denial alignment
- Partner with analytics teams to:
  - Define data elements (IRF PAI, ICD 10, LOS, CMG weights)
  - Build prioritization logic for claim selection
- Draft audit rationales, findings summaries, and client-facing reports
Regulatory Expertise & SME Leadership
- Serve as internal SME on:
  - CMS IRF PPS rules
  - CMG Grouper updates and annual recalibration
  - Comorbidity tiering changes and exclusions
- Interpret CMS rule updates and translate into:
  - Operational guidance
  - Audit logic enhancements
- Provide education and training to internal teams and clients
Cross-Functional Collaboration
- Partner with:
  - Clinical teams (therapy, nursing documentation)
  - Coding teams (ICD 10 and IRF PAI specialists)
  - Payment integrity and recovery teams
- Support product development and strategy for IRF-related solutions

You’ll be rewarded and recognized for your performance in an environment that will challenge you and give you clear direction on what it takes to succeed in your role as well as provide development for other roles you may be interested in.

Required Qualifications:

Clinical Licensure - Hold a license in one of the following : RN, PT, OT, SLP
Coding Licensure - RHIA, RHIT, CCS, or CPC with strong IRF experience
5+ years of experience in one or more of the following:
Inpatient Rehabilitation Facility (IRF) coding or auditing
IRF PAI completion and functional scoring
Payment integrity, DRG/CMG validation, or audit recovery
Experience applying CMS regulatory guidance in an audit or compliance setting
Demonstrated expertise in:
- CMG assignment methodology
- IRF PPS payment structure
- Comorbidity tiering logic and ICD 10 application

Preferred Qualifications:

CCS (Certified Coding Specialist)
CPC (Certified Professional Coder)
CRC (Certified Risk Adjustment Coder)
CDIP (Clinical Documentation Improvement Practitioner)
Experience in payment integrity / recovery audits (vs. only facility coding)
Experience identifying tiering eligibility exclusions or misclassification
Proven background in functional scoring validation (GG items)
Proven exposure to IRF Grouper tools or CMS Web Pricer logic
Proven ability to translate findings into financial impact narratives

Core Competencies

Deep IRF PPS knowledge (CMG, IRF PAI, tiering)
Solid clinical documentation…