Quality Analyst IV – Healthcare

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

📋 Description

• Conduct random, targeted, follow-up, and focused quality assessments of finalized IRF audits.

• Confirm the accuracy of audit findings, documentation support, coding logic, reimbursement implications, and audit justifications.

• Adhere to established sampling methodologies and quality review protocols.

• Utilize quality scoring criteria to assess audit precision, documentation quality, client specifications, and EXL standards.

• Ensure that IRF audit decisions are substantiated by the IRF-PAI, UB-04/final billing, discharge summaries, complete IRF medical records, therapy and physician documentation, nursing notes, MAR, pre-admission screenings, care plans, interdisciplinary team documentation, CMS guidelines, payer prerequisites, and internal procedures.

• Validate the accuracy of IRF-PAI completion and its supporting documentation, including impairment groups, etiologic diagnoses, dates of onset, comorbid conditions, complication/comorbidity reporting, treatments received, and reimbursement validation.

• Examine audit documentation for clarity, thoroughness, grammar, evidence-based support, and adherence to quality standards.

• Detect discrepancies in documentation, coding, and reimbursement that could impact IRF payments.

• Offer professional feedback and coaching to IRF Auditors, highlighting corrections and areas for improvement.

• Recognize audit patterns, recurrent errors, documentation deficiencies, inconsistent audit reasoning, and needs for process enhancement or training.

• Conduct root cause analyses and suggest corrective measures.

• Assist in calibration discussions, quality oversight, score evaluations, SOP revisions, and training opportunities.

• Draft communications that outline quality outcomes, findings, justifications, trends, coaching suggestions, and subsequent steps.

• Maintain records of quality review outcomes and reporting for performance tracking, trend analysis, leadership evaluation, and quality enhancement.

• Relay quality findings, risks, trends, and recommendations to colleagues and management.

• Keep abreast of updates concerning IRF reimbursement, CMS guidelines, IRF-PAI manual modifications, ICD-10-CM/PCS updates, payer policies, and internal procedures.

• Fulfill responsibilities in accordance with company compliance, information security, HIPAA, and regulatory policies.

⛳️ Requirements

• A minimum of a High School Diploma is required.

• An Associate’s or Bachelor’s degree in Health Information Management, healthcare administration, nursing, rehabilitation services, or a related healthcare discipline is preferred.

• CCS, RHIA, RHIT, CIC, CPC, or equivalent coding credentials are preferred; multiple coding credentials are highly favored.

• A minimum of 5 years of experience in inpatient facility coding, auditing, payment integrity, reimbursement review, quality assessment, audit validation, or related healthcare roles is preferred.

• Extensive experience with IRF audits, IRF coding, IRF reimbursement, IRF-PAI, or rehabilitation facility documentation review is strongly preferred.

• A solid understanding of ICD-10-CM/PCS, inpatient facility claim evaluations, medical record abstraction, documentation validation, payer reimbursement methods, audit scoring criteria, and the correlation between documentation, coded data, IRF-PAI elements, and reimbursement results.

• Proven experience in identifying quality errors, missed chances, documentation shortcomings, inconsistent audit application, and trends within complex inpatient or IRF audit tasks.

• Experienced in reviewing extensive medical records and correlating documentation with reimbursement impacts, treatments during the IRF stay, payer/client requirements, and audit findings.

• Capability to provide constructive, specific, and actionable feedback to auditors.

• Ability to objectively assess auditor performance and differentiate IRF-PAI documentation needs from traditional acute-care DRG coding principles.

• Strong analytical, problem-solving, root cause analysis, and critical thinking abilities with exceptional attention to detail.

• Excellent written and verbal communication skills.

• Ability to work independently in a remote setting while ensuring quality, productivity, confidentiality, and timely completion.

• Proficiency in Excel, Word, Outlook, OneNote, and general computer applications.

• Familiarity with audit workflow tools, coding references, encoder tools, and medical record review platforms is preferred.

• A commitment to teamwork, calibration, continuous learning, process improvement, and delivering accurate audit results.

• Compliance with HIPAA regulations.

🏝️ Benefits

• Up to 10% annual travel for team meetings and limited client onsite engagements.

• Benefits information is available through EXL US Careers and Benefits.

• Opportunity for remote work from home.