QA - HIM Services

About the role

Our purpose is to help clients exceed their financial health goals. Across the reimbursement cycle, our scalable solutions and clinical expertise help solve programmatic needs. Enabling our teams with leading technology allows analytics to guide our solutions and keeps us accountable achieving goals. We build long-term careers by investing in YOU. We seek to create an environment that cultivates your professional development and personal growth, as we believe your success is our success. ESSENTIAL DUTIES AND RESPONSIBILITIES: Note: The essential duties and responsibilities below are intended to describe the general duties and responsibilities of this position and are not intended to be an exhaustive statement of duties. This position may perform all or most of the primary duties listed below. Specific tasks, responsibilities or competencies may be documented in the Team Member's performance objectives as outlined by the Team Member's immediate Leadership Team Member. Roles and Responsibilities: Auditing and reviewing medical documentation for appropriate ICD and CPT coding and ensuring that codes tally with doctors' diagnosis. Asking explanation from physicians when code assignments are not straightforward or documentation in the record is inadequate, ambiguous, or unclear for coding purposes Ensuring compliance with medical coding policies and guidelines. Be updated about new coding rules as codes change from time to time. Collecting and distributing coding related information and billing issues. Exceptional Knowledge of medical terminology, anatomy, physiology, disease processes, and pharmacology. Work as part of a team and achieve the team quality and productivity standards. Required Expertise & Qualification: A Medical Coding Edits and Denial Quality Analyst plays a critical role in auditing the denials. This position focuses on ensuring the accuracy of medical coding, identifying patterns in insurance denials, and implementing strategies to maximize reimbursement and maintain compliance. Below is a job description template that can be adapted for a hospital, physician group, or billing service. Job Title: HIM QA SERVICES Department: HIM QA Reports To: AM Job Summary The Medical Coding Edits and Denial Quality Analyst is responsible for analyzing, reviewing, and resolving coding-related claim edits and insurance denials. This role involves performing root-cause analysis on denied claims, identifying coding trends that lead to financial loss, and providing feedback to the coding and clinical teams. The goal is to ensure "clean claim" submission, reduce the denial rate, and payer-specific regulations.

Responsibilities

• Denial Management & Root Cause Analysis
• Analyze daily claim denials related to coding (ICD-10-CM, CPT, HCPCS, and Modifiers).
• Perform deep-dive "root cause analysis" to determine why claims are being rejected (e.g., lack of medical necessity, unbundling, incorrect modifiers).
• Collaborate with the billing and follow-up teams to appeal denials and recover lost revenue.
• Coding Edit Resolution
• Review and clear pre-billing edits (e.g., NCCI, MUE, LCD/NCD, and internal "scrubber" edits).
• Correct coding errors in the Electronic Health Record (EHR) system before claims are sent to payers.
• Identify recurring system edits that require logic updates within the billing software.
• Quality Assurance & Auditing
• Perform prospective and retrospective coding quality audits to ensure accuracy and compliance.
• Monitor the accuracy of DRG (Inpatient) or APC (Outpatient) assignments.
• Validate that documentation in the medical record supports the codes billed.
• Reporting and Data Analytics
• Develop and maintain "Denial Dashboards" to track trends by payer, provider, or specialty.
• Present monthly reports to leadership regarding denial rates, recovery amounts, and areas for improvement.
• Use Excel (Pivot Tables, VLOOKUPs) or BI tools to manipulate large sets of claims data.
• Provider & Staff Education
• Provide feedback and training to medical coders regarding updated coding guidelines.
• Collaborate with physicians and clinical staff to improve documentation specificity (Clinical Documentation Improvement - CDI).
• Develop educational materials to prevent future denials.
• Compliance & Policy Maintenance
• Stay current on annual ICD-10 and CPT code changes, OIG work plans, and Payer Bulletins.
• Ensure all coding activities adhere to HIPAA regulations and CMS guidelines.
• Required Skills & Qualifications
• Coding Expertise: Expert knowledge of CPT, ICD-10-CM/PCS, HCPCS Level II, and Modifier usage.
• Regulatory Knowledge: Deep understanding of NCCI (National Correct Coding Initiative) edits, MUE (Medically Unlikely Edits), and LCD/NCD (Local/National Coverage Determinations).
• Analytical Thinking: Ability to spot patterns in large datasets and translate data into actionable process improvements.
• Technical Proficiency: Advanced experience with EHR systems (e.g., Epic, Cerner, Medit

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