IRF Quality Analyst IV - Healthcare at EXL in United States

Job description

• The IRF Quality Analyst performs random, targeted, and follow-up quality reviews to confirm that audit determinations are supported by the IRF-PAI, UB-04/final bill, acute inpatient discharge summary, complete IRF medical record, therapy documentation, physician documentation, nursing documentation, physician orders, MAR, pre-admission screening, individualized overall plan of care, and interdisciplinary team documentation. This position requires strong IRF audit knowledge, sound judgment, attention to detail, and the ability to determine whether auditor conclusions are fully supported by the record, aligned with client and program requirements, and clearly explained. The analyst identifies quality trends, provides feedback and coaching support to auditors, participates in calibration, and recommends process improvements that strengthen audit accuracy, documentation quality, consistency, and overall program performance.

Responsibilities

• Apply IRF audit, coding, reimbursement, and documentation expertise to evaluate the accuracy and consistency of completed IRF Auditor work.
• Perform random, targeted, follow-up, and focused quality reviews of completed IRF audits to validate findings, no-findings, documentation support, coding logic, reimbursement impact, and audit rationale.
• Follow approved sampling methodology and quality review procedures to ensure reviews are completed consistently, objectively, and in alignment with program expectations.
• Apply established quality scoring criteria to evaluate audit accuracy, documentation quality, adherence to client requirements, and alignment with EXL quality standards.
• Confirm that IRF audit determinations are supported by the IRF-PAI, UB-04/final bill, acute inpatient discharge summary, complete IRF medical record, therapy documentation, physician orders and notes, nursing notes, MAR, history and physical, pre-admission screening, individualized overall plan of care, interdisciplinary team documentation, applicable CMS/IRF-PAI guidance, payer requirements, and internal procedures.
• Validate IRF-PAI completion and supporting documentation, including impairment group, etiologic diagnosis, date of onset, comorbid conditions, complication/comorbidity reporting, treatment received during the IRF stay, and documentation needed to support reimbursement impact.
• Review audit documentation for clarity, completeness, grammar, evidence-based support, and alignment with EXL communication and quality expectations.
• Identify documentation, coding, and reimbursement discrepancies that may impact IRF payment, including unsupported diagnoses, unsupported comorbidities, diagnoses carried forward from the prior acute inpatient stay without IRF-level support, mismatches between record documentation and audit conclusions, and missed opportunities for additional review or escalation.
• Provide clear, professional feedback and coaching support to IRF Auditors based on quality review outcomes, including specific examples, expected corrections, coaching points, and opportunities for improvement.
• Use IRF, coding, reimbursement, and payment integrity knowledge to identify audit trends, recurring errors, documentation gaps, inconsistent application of audit logic, and potential process or training needs.
• Perform root cause analysis on quality errors and recommend corrective actions to improve audit accuracy, documentation quality, productivity, consistency, and overall performance.
• Support calibration discussions, quality monitoring, quality score review, standard operating procedure updates, and training opportunities to promote consistent audit application across the IRF program.
• Write professional communications documenting quality review outcomes, audit findings, supporting rationale, error trends, coaching recommendations, and next steps.
• Maintain quality review results and reporting to support performance monitoring, trend analysis, leadership review, auditor coaching, and ongoing quality improvement.
• Communicate quality results, barriers, risks, trends, and improvement recommendations to peers and management in a timely and professional manner.
• Stay current with IRF reimbursement updates, CMS guidance, IRF-PAI manual updates, ICD-10-CM/PCS coding updates, payer-specific policy changes, and internal program procedures.
• Conduct all job functions and responsibilities in accordance with all company Compliance, Information Security, HIPAA, regulatory policies, procedures, and programs.

Requirements

• Minimum High School Diploma required; associate’s or bachelor’s degree in Health Information Management, healthcare administration, nursing, rehabilitation services, or a related healthcare field preferred.
• CCS, RHIA, RHIT, CIC, CPC, or comparable coding credential preferred; multiple coding credentials strongly preferred.
• Strong preference for candidates with demonstrated IRF audit, IRF coding, IRF reimbursement, IRF-PAI, or rehabilitation facility documentation review experience.
• Clinical licensure, rehabilitation facility experience, or prior IRF medical necessity review experience is a plus when client scope includes clinical review components; active RN licensure is not required unless specified by client scope.
• 5+ years of inpatient facility coding, auditing, payment integrity, reimbursement review, quality review, audit validation, or related healthcare experience preferred.
• Prior experience reviewing IRF audits, IRF-PAI documentation, IRF PPS/HIPPS methodology, rehabilitation facility documentation, inpatient rehabilitation reimbursement, or audit quality monitoring is highly desirable.
• Strong understanding of ICD-10-CM/PCS, inpatient facility claim review, medical record abstraction, documentation validation, payer reimbursement methodologies, audit scoring expectations, and the relationship between documentation, coded data, IRF-PAI elements, and reimbursement outcomes.
• Experience identifying quality errors, missed opportunities, documentation gaps, inconsistent audit application, and trends in complex inpatient or IRF audit work.
• Experience reviewing lengthy medical records and tying documentation to reimbursement impact, treatment during the IRF stay, payer/client requirements, and the support for audit findings.
• Ability to provide constructive feedback to auditors in a professional, specific, and actionable manner while supporting consistency, learning, and quality improvement across the program.
• Strong IRF quality review mindset with the ability to evaluate auditor work objectively, identify unsupported conclusions, and distinguish IRF-PAI documentation requirements from traditional acute-care DRG coding logic.
• Ability to synthesize complex IRF medical record documentation, identify quality errors or missed opportunities, and make objective, evidence-based quality determinations.
• Strong analytical, problem-solving, root cause analysis, and critical-thinking skills with excellent attention to detail and a high standard for documentation accuracy.
• Excellent written and verbal communication skills, including the ability to provide professional feedback, write clear quality rationale, explain audit decisions, and communicate trends to leadership.
• Self-motivated and able to work independently in a remote environment while maintaining high quality, productivity, confidentiality, and timely completion of assigned quality reviews.
• Proficient in Excel, Word, Outlook, OneNote, and general computer applications; experience with audit workflow tools, coding references, encoder tools, and medical record review platforms preferred.
• Commitment to teamwork, calibration, continuous learning, consistent quality application, process improvement, and accurate audit outcomes.
• IRF Quality Review
• Inpatient Rehabilitation Facility (IRF)
• IRF-PAI Validation
• IRF PPS / HIPPS Methodology
• Medical Record Review
• Audit Sampling
• Quality Scoring
• Documentation Validation
• Root Cause Analysis
• Quality Feedback
• Calibration
• Trend Identification
• Written Communication
• HIPAA Compliance
• APR-DRG
• Attention To Consistency
• Computer Literacy
• DRG
• Diagnosis-Related Group (DRG) Experience
• IRF-PAI
• Internal Communications
• Interpersonal Relationship Building
• Leadership Capabilities
• MS-DRG
• Microsoft Excel
• Microsoft Word
• Quality Analyst
• Working under Pressure

Skills

Required

• IRF Quality Review
• Inpatient Rehabilitation Facility (IRF)
• IRF-PAI Validation
• IRF PPS / HIPPS Methodology
• ICD-10-CM/PCS
• Medical Record Review
• Audit Sampling
• Quality Scoring
• Documentation Validation
• Root Cause Analysis
• Quality Feedback
• Calibration

Preferred

• Multiple coding credentials
• APR-DRG
• DRG
• MS-DRG
• IRF-PAI
• Microsoft Excel
• Microsoft Word
• Computer Literacy

Benefits

• $70,000 - $110,000
• Based on experience, skills, and qualifications
• The posted base salary range is the hiring base salary range for this role. Final offers are based on several factors, including: the candidate's skills and experience, internal pay equity, work location, market conditions for the role, and the specific scope and responsibilities of the position.