Inpatient Rehabilitation SME - Remote

UnitedHealth Group•Plymouth, MN

7d•$112,700 - $193,200•Remote

About The Position

The IRF CMG Coding & Payment Integrity SME leads clinical and coding validation related to the CMS Inpatient Rehabilitation Facility (IRF) Prospective Payment System (PPS), focusing on Case Mix Group (CMG) assignment, IRF PAI functional scoring, and comorbidity tiering accuracy. The role works across clinical, coding, and analytics teams to identify, validate, and recover payment variances caused by documentation gaps, functional-scoring discrepancies, and incorrect comorbidity-tier assignments. The position is remote within the United States. Employees hired in the Minneapolis or Washington, D.C. area must work in the office at least four days per week. Remote employees must follow UnitedHealth Group’s Telecommuter Policy. The role supports IRF audit and recovery strategies, regulatory interpretation, internal and client education, and product development. The stated annual salary range is $112,700–$193,200, based on full-time employment, and the posting notes a comprehensive benefits package, incentive and recognition programs, equity stock purchase, and 401(k) contribution, subject to eligibility requirements.

Requirements

Hold a clinical license as an RN, PT, OT, or SLP.
Hold a coding credential of RHIA, RHIT, CCS, or CPC, with strong IRF experience.
Have at least 5 years of experience in one or more of the following: IRF coding or auditing; IRF PAI completion and functional scoring; or 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.
Strong clinical documentation interpretation skills and ability to connect documentation, coding, and payment outcomes.
Audit and investigative mindset, including root-cause analysis and assessment of financial impact.
Experience reviewing large datasets and identifying trends.
Solid communication skills for client-facing reporting.

Nice To Haves

CCS (Certified Coding Specialist).
CPC (Certified Professional Coder).
CRC (Certified Risk Adjustment Coder).
CDIP (Clinical Documentation Improvement Practitioner).
Experience in payment integrity or recovery audits, beyond facility coding alone.
Experience identifying tiering eligibility exclusions or misclassification.
Background in functional-scoring validation for GG items.
Exposure to IRF Grouper tools or CMS Web Pricer logic.
Ability to translate findings into financial-impact narratives.

Responsibilities

Review IRF cases to validate CMG assignment accuracy, IRF PAI Section GG functional-scoring integrity, and comorbidity tier assignments.
Identify and quantify overpayments and underpayments resulting from CMG or tiering misclassification.
Apply CMS Grouper logic to validate expected CMG outcomes.
Evaluate consistency among medical-record documentation, IRF PAI functional scores, ICD-10 coding, and comorbidity capture.
Lead clinical validation of the etiologic diagnosis and comorbidity eligibility for tiering.
Identify unsupported functional scores, incorrect diagnosis sequencing, and missed or invalid tier opportunities.
Support CMG-focused audit strategies, including targeting high-weight CMGs, identifying tiering-driven opportunities, and mapping CARC/RARC codes to denials.
Partner with analytics teams to define data elements, develop claim-prioritization logic, and prepare audit rationales, findings summaries, and client-facing reports.
Serve as an internal subject matter expert on CMS IRF PPS rules, CMG Grouper updates and annual recalibration, and comorbidity tiering changes and exclusions.
Interpret CMS rule updates and translate them into operational guidance and audit-logic enhancements.
Provide education and training to internal teams and clients.
Collaborate with clinical, coding, payment-integrity, and recovery teams.
Support product development and strategy for IRF-related solutions.