IRF Quality Analyst IV - Healthcare

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.

A quality review, IRF audit validation, coding/auditing assessment, or written documentation assessment may be included as part of the interview process.

For more information on benefits and what we offer, please visit: https://www.exlservice.com/us-careers-and-benefits

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.

Qualifications

Education & Credentials:

• 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.

Experience & Expertise:

• 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.

Key Skills & Attributes:

• 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.

Required Skills:

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.

EXL (NASDAQ: EXLS) is a leading data analytics and digital operations and solutions company. We partner with clients using a data and AI-led approach to reinvent business models, drive better business outcomes and unlock growth with speed. EXL harnesses the power of data, analytics, AI, and deep industry knowledge to transform operations for the world’s leading corporations in industries including insurance, healthcare, banking and financial services, media and retail, among others. EXL was founded in 1999 with the core values of innovation, collaboration, excellence, integrity and respect. We are headquartered in New York and have more than 54,000 employees spanning six continents. For more information, visit www.exlservice.com.

EXL never requires or asks for fees/payments or credit card or bank details during any phase of the recruitment or hiring process and has not authorized any agencies or partners to collect any fee or payment from prospective candidates. EXL will only extend a job offer after a candidate has gone through a formal interview process with members of EXL’s Human Resources team, as well as our hiring managers.

EXL is the indispensable partner for leading businesses in data-led industries such as insurance, banking and financial services, healthcare, retail and logistics. We bring a unique combination of data, advanced analytics, digital technology and industry expertise to help our clients turn data into insights, streamline operations, improve customer experience, and transform their business. Our partnerships with clients are built on a foundation of collaboration – and we’ve been chosen as a partner by nine of the top ten leading US insurance companies, nine of the top 20 global banks, and six of the top ten US health care payers. We function as one team to make your goals our goals, whether that’s unlocking the value of generative AI or embedding analytics into workflows that reduce risk or power your growth. Clients choose EXL as their transformation partner for many reasons. Our geographic diversity make talent all over the world instantly accessible. Digital accelerators enable unmatched speed-to-value, letting you realize results fast. It’s our people that truly set us apart, though, including the 1,500 data scientists we have dedicated to our generative AI practice. And our more than twenty years of experience in delivering business services, garnering stellar client references, and maintaining a solid balance sheet are reassuring to our C-suite clients. Find out for yourself why clients, employees, and analysts think we’re some of the best in the business. Contact us to see how we can help you achieve your goals.