Outpatient Quality Manager

This is a fully remote position, open to applicants in United States.

📋 Description

• Oversee the implementation and continuous enhancement of outpatient coding quality review programs, which encompass initial audits, appeals, targeted reviews, provider- or concept-specific evaluations, and ATA audits.

• Supervise daily outpatient quality review operations, including the distribution of workflow, inventory management, QA aging, productivity tracking, adherence to client SLAs, quality expectations, and compliance with internal standards.

• Provide direct oversight to outpatient quality analysts through coaching, feedback, performance evaluations, one-on-one sessions, training, development planning, and skill enhancement.

• Evaluate audit accuracy, productivity levels, QA inventory, defect trends, root causes, auditor performance, documentation patterns, and quality metrics to enhance team performance and quality outcomes.

• Conduct ATA audits and verify that determinations, documentation support, rationales, and outcomes are precise and consistent.

• Ensure RCA categories are accurately marked, and that recurring trends receive necessary follow-ups, coaching, clarifications, process corrections, or escalations.

• Facilitate regular calibration sessions with outpatient quality analysts.

• Collaborate with Operations, Training, Technology, clients, and global partners to address issues and support audit quality solutions.

• Assist in program implementations and operational initiatives by defining quality expectations, review criteria, sampling methodologies, workflow requirements, reporting needs, and quality controls.

• Identify opportunities for responsible AI integration into workflows while ensuring human review, compliance, and data security standards are upheld.

• Stay updated on CMS, payer, LCD/NCD, NCCI, OPPS/APC, CPT, HCPCS, modifier, and ICD-10-CM guideline revisions.

• Execute all responsibilities in alignment with Compliance, Information Security, and Regulatory policies.

⛳️ Requirements

• CCS, CPC, RHIT, RHIA, or another relevant coding credential is required; CCS or CPC is preferred.

• A minimum of 5 years of experience in outpatient facility coding, auditing, or quality review is required.

• Knowledge of ICD-10-CM, CPT, HCPCS, modifiers, OPPS, APC reimbursement, and outpatient payment methodologies is essential.

• Prior experience in leadership, supervisory roles, quality management, or as a team lead is necessary.

• Familiarity with applying Medicare LCDs, NCDs, NCCI edits, payer policies, and medical necessity requirements is required.

• Experience in outpatient audit operations, quality assurance, root cause analysis, coaching, and performance improvement is essential.

• Strong expertise in outpatient coding across complex facility services is crucial.

• Proficiency in modifier application, CPT/HCPCS coding, ICD-10-CM coding, NCCI edits, MUEs, and Medicare/payer-specific guidelines is necessary.

• Capability to assess audit accuracy and validate findings, no-findings, rationales, documentation, and coding guidance is required.

• Ability to draft professional quality notes referencing Official Coding Guidelines, Coding Clinic, AMA CPT Assistant, CMS guidance, LCD/NCD policies, and other recognized sources is essential.

• Strong leadership, coaching, mentoring, verbal and written communication, analytical skills, root cause analysis, decision-making, problem-solving, organizational, and attention-to-detail capabilities are required.

• Competence in managing competing priorities, inventory, and deadlines is necessary.

• Ability to work both independently and collaboratively with Operations, Training, Technology, clients, and global partners is essential.

• Flexibility, adaptability, accountability, and sound judgment in a dynamic audit environment are required.

• Technical knowledge and the ability to learn audit tools, reporting platforms, and workflow systems are essential.

• Skill in leveraging approved AI-enabled tools and workflow technologies is necessary.

• Proficiency with Excel, PowerPoint, Outlook, Word, and audit productivity/reporting tools is required.

🏝️ Benefits

• Thrilling, fast-paced, and innovative work environment.

• Opportunity to collaborate closely with seasoned, world-class Healthcare consultants.

• Opportunities to gain insight into multiple facets of clients’ businesses.

• Mentoring program offering guidance and coaching from senior-level professionals.

• Opportunities for both personal and professional development.

• Potential for further advancement and growth within the company and beyond.

• Limited travel may be necessary for team meetings.

• Option to work remotely from home.