Quality Validation Specialist

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

📋 Description

• Conducts secondary reviews of finalized outpatient coding validation audits to confirm coding precision, justification, and adherence to official coding standards, payer regulations, reimbursement strategies, and internal auditing criteria.

• Assesses auditor performance against defined quality and accuracy metrics, pinpointing patterns, educational needs, and areas that necessitate corrective measures.

• Offers specific, constructive criticism and coaching to auditors to foster consistency, accuracy, and the correct interpretation and application of coding and billing standards.

• Creates, maintains, and improves quality assurance tools, scorecards, audit tracking systems, and documentation standards to facilitate objective and uniform review processes.

• Works collaboratively with leadership and operational teams to enhance audit methodologies, clarify coding instructions, standardize procedures, and bolster continuous quality improvement initiatives.

• Confirms the precise assignment and evaluation of CPT, HCPCS Level II, and ICD-10-CM codes, including the correct use of modifiers and reference materials such as Official Coding Guidelines, CMS regulations, AMA guidance, LCDs, and NCDs.

• Develops and maintains QA tools, scorecards, and documentation standards to bolster objective review processes.

• Tracks and reports QA metrics, audit outcomes, quality trends, and corrective action plans to leadership for performance oversight and operational enhancement.

• Keeps abreast of current outpatient reimbursement methodologies, regulatory updates, coding alterations, and industry benchmarks related to Medicare OPPS, APCs, and EAPGs.

• Ensures compliance with ethical coding and auditing standards set by AHIMA, AAPC, CMS, and the organization’s compliance policies.

• Executes secondary reviews across various audit and coding platforms while adhering to established productivity and quality standards.

• Aids in the creation and delivery of training materials and educational resources pertaining to identified trends, coding updates, policy modifications, and performance improvement opportunities.

• Engages in calibration sessions and quality consistency initiatives to ensure uniform audit interpretation and scoring methodologies.

• Undertakes additional responsibilities as assigned.

⛳️ Requirements

• An Associate’s or Bachelor’s degree in Health Information Management, Healthcare Administration, or a related discipline is preferred.

• Current certification from AHIMA and/or AAPC is required, including one or more of the following:

• RHIA (Registered Health Information Administrator)

• CCS (Certified Coding Specialist)

• CPC (Certified Professional Coder)

• At least 5 years of experience in hospital outpatient coding within OPPS reimbursement methodologies and/or a minimum of 5 years of outpatient/APC validation auditing experience.

• Extensive understanding of CPT, HCPCS Level II, ICD-10-CM, NCCI edits, and appropriate modifier application.

• Strong familiarity with Medicare Outpatient Prospective Payment System (OPPS), Ambulatory Payment Classifications (APCs), and outpatient reimbursement methodologies.

• Proficient in interpreting and applying Medicare LCD and NCD guidelines.

• Experience with industry-standard encoder and auditing tools such as Optum, TrueBridge, and/or 3M.

• Proven ability to review and validate a wide variety of outpatient facility services and claim types.

• Strong analytical, critical thinking, organizational, and problem-solving abilities.

• Exceptional verbal and written communication skills, capable of providing clear, professional feedback and education.

• Ability to operate independently and collaboratively in a fast-paced, production-oriented, and quality-driven environment.

🏝️ Benefits

• PTO, Paid Holidays, and Volunteer Days

• Eligibility for health, vision, and dental insurance, participation in a 401(k) plan with company matching, and flexible spending accounts

• Tuition Reimbursement

• Eligibility for company-sponsored benefits including life insurance, short-term disability, and parental leave.

• Options for remote and hybrid work arrangements