Director of IRF Compliance Revenue Integrity and Performance Improvement

General Summary of Position

The Director of IRF Compliance Revenue Integrity and Performance Improvement (PI) provides strategic leadership and operational oversight for IRF regulatory compliance IRF-PAI integrity reimbursement optimization within the Inpatient Rehabilitation Facility (IRF) and leads associated performance improvement efforts.This role ensures full compliance with CMS IRF-PPS regulations CMS Final Rule requirements medical necessity standards and documentation integrity practices. The Director serves as the organizational subject matter expert for IRF regulatory interpretation denial mitigation appeal strategy and interdisciplinary alignment to support clinical excellence and financial sustainability.The Director partners closely with executive leadership physicians Quality Compliance and Revenue Cycle to mitigate regulatory risk optimize Case-Mix Index (CMI) and ensure accurate and defensible reimbursement.

Primary Duties and Responsibilities

• Provides oversight of IRF-PAI processes to ensure compliance with current CMS IRF-PPS regulations and CMS Final Rule updates.
• Interprets and operationalizes CMS regulatory changes including Quality Indicator requirements coverage criteria and documentation standards.
• Ensures organizational readiness for regulatory audits (MAC RAC OIG commercial payer audits).
• Leads proactive compliance risk assessments and develops mitigation strategies to reduce exposure.
• Collaborates with PPS /CMG coordinators and Utilization Management team to ensure accurate and timely completion and transmission of IRF-PAI assessments to CMS/eRehab.
• Ensures validation and accuracy of Quality Indicator documentation to support appropriate Case-Mix Group (CMG) assignment and optimal CMI performance.
• Facilitates performance improvement efforts related to rehabilitation compliance. Develops KPIs related to CMG optimization CMI performance and documentation integrity.
• Responsible for oversight of IRF-related denial prevention and management programs.
• Authors and/or oversees development of comprehensive appeal letters that clearly articulate clinical justification and regulatory support aligned with CMS guidelines.
• Establishes standardized appeal workflows and tracking mechanisms for denial trends and overturn rates. Analyzes denial data to identify systemic documentation or operational vulnerabilities and implements corrective action plans.
• Develops strategies to reduce avoidable denials related to level of care determinations.
• Provides education to physicians therapists nursing staff and interdisciplinary team members regarding documentation standards impacting IRF-PAI accuracy and medical necessity; this included the development of training programs related to CMS Final Rule and Quality Indicator coding.
• Monitors performance indicators including: IRF-PAI completion accuracy CMG accuracy CMI trends denial rates and overtun percentages length-of-stay benchmarks.
• Leads performance improvement initiatives to enhance regulatory compliance and reimbursement integrity.

Minimal Qualifications
Education

• Bachelor's degree Healthcare Administration Business Nursing Rehabilitation (PT OT SLP) or related discipline required
• Master's degree Healthcare Administration Business Nursing Rehabilitation (PT OT SLP) or related discipline. preferred

Experience

• 3-4 years Progressive leadership experience in complex regulatory healthcare environments required
• 5-7 years Experience in an inpatient rehabilitation setting. preferred

Licenses and Certifications

• RN - Registered Nurse - State Licensure and/or Compact State Licensure required or
• PT - Physical Therapist required or
• OT - Occupational Therapist required or
• SLP - Speech Language Practitioner required

Knowledge Skills and Abilities

• IRF-PPS & CMS Final Rule Expertise
• Revenue Integrity & Denials Mitigation
• Clinical Documentation Excellence
• Performance Improvement & Data Analytics
• Interdisciplinary Leadership & Influence