Inpatient Rehabilitation SME - Remote

UnitedHealth Group; Plymouth (MN); Hybride; USD 120 000 - 180 000; Plein temps

Résumé du poste

UnitedHealth Group is seeking an IRF CMG Coding & Payment Integrity SME to lead validation of CMG assignments, functional scoring, and comorbidity tiering for CMS IRF PPS. You will collaborate across clinical, coding, and analytics teams to recover payment variances by addressing documentation gaps and scoring discrepancies.

The role requires licensure in clinical fields and coding credentials; remote work is supported nationwide with in-office requirements in certain hubs.

Qualifications

• 5+ years of IRF coding or auditing experience.
• Expertise in CMG assignment and IRF PAI scoring.
• Experience applying CMS guidance in audits or compliance.

Responsabilités

• Lead clinical validation for etiologic diagnosis and comorbidity tiering.
• Review IRF cases for CMG and tiering accuracy and coding integrity.
• Identify overpayments/underpayments tied to scoring and tiering.
• Develop audit strategies focusing on high-weight CMGs.
• Provide client-facing audit rationales and reports.

Connaissances

IRF PPS knowledge

CMG assignment methodology

IRF PAI understanding

Data analysis

Auditing

Communication skills

Formation

Clinical Licensure in RN/PT/OT/SLP

RHIA/RHIT/CCS/CPC

Outils

IRF Grouper tools

CMS Web Pricer

Description du poste

Optum Insight is improving the flow of health data and information to create a more connected system. We remove friction and drive alignment between care providers and payers, and ultimately consumers. Our deep expertise in the industry and innovative technology empower us to help organizations reduce costs while improving risk management, quality and revenue growth. Ready to help us deliver results that improve lives? Join us in making healthcare work better for everyone through people-led, responsible AI while Caring. Connecting. Growing together.

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 overpayments 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 interpretation skills
• Ability to link documentation coding payment outcomes
• Audit and investigative mindset (root cause + financial impact)
• Experience with large dataset review and trend identification
• Solid communication skills for client-facing reporting

Success Profile (What 'great' looks like in this role)

• Consistently identifies high-value CMG/tiering opportunities
• Detects documentation vs IRF PAI inconsistencies
• Improves audit yield by focusing on:
  • High-weight CMGs
  • Tier 2/3 cases
• Serves as a trusted SME for both clinical and coding validation

*All employees working remote…