QA - HIM Services

About Us:

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:

 Life Science graduation or any equivalent graduation with Anatomy/Physiology as
main subjects
 3 to 5 years of work experience as a medical coder.
 Any one of the following coding certifications CPC, COC, CRC, CPCP from AAPC CCS,
CCSP, CCA from AHIMA
 Proficient computer skills.
 Excellent communication skills, both verbal and written.
 Strong people skills & Outstanding organizational skills.
 Ability to maintain the confidentiality of information.

An OB/GYN Surgery Auditor is a specialized role focused on ensuring the accuracy, compliance, and clinical integrity of surgical documentation and coding within an obstetrics and gynecology practice or hospital department. This role bridges the gap between clinical performance and financial health by identifying revenue risks and ensuring adherence to federal and state regulations.[1]

Below is a comprehensive job description for an OB/GYN Surgery Auditor.

Job Summary

The OB/GYN Surgery Auditor is responsible for reviewing operative reports, clinical documentation, and billing claims to ensure accurate assignment of ICD-10-CM, CPT, and HCPCS codes for surgical procedures. This role involves identifying coding trends, preventing claim denials, and providing educational feedback to physicians and coding staff. The auditor ensures that all surgical services—ranging from routine deliveries to complex gynecologic oncology procedures—are documented according to CMS and payer-specific guidelines.

Key Responsibilities

• Documentation & Coding Review: Conduct regular retrospective and prospective audits of surgical operative reports to verify that documented procedures match the billed codes (e.g., hysterectomies, laparoscopies, cesarean sections).
• Compliance Monitoring: Ensure all coding practices follow official guidelines, including the National Correct Coding Initiative (NCCI) and the OIG Work Plan.
• Global Package Management: Audit claims for adherence to "Global Surgical Package" rules, ensuring that pre-operative and post-operative visits are correctly bundled or separated with appropriate modifiers (e.g., -25, -57, -58).
• Revenue Integrity: Identify "revenue leakage" where procedures are performed but not documented or billed correctly.
• Provider Education: Develop and deliver training sessions for OB/GYN surgeons on clinical documentation improvement (CDI) to reduce errors and improve "billable" detail in operative notes.
• Denial Management: Review and analyse claim denials related to surgical coding; assist in the preparation of expert appeal letters to payers.
• Reporting: Generate detailed audit reports for leadership, highlighting accuracy rates, potential compliance risks, and financial impact.

Required Qualifications & Skills

• Education:  a related field (or equivalent experience).
• Core Certifications (Required):
  • CPC (Certified Professional Coder) or CCS-P (Certified Coding Specialist-Physician-based).
• Specialty Certifications (Highly Preferred):
  • COBGC (Certified Obstetrics and Gynaecology Coder).
  • CPMA (Certified Professional Medical Auditor).
• Experience: 3–5 years of specialized coding experience in OB/GYN surgery. Proven experience in medical auditing or a "quality analyst" role.
• Anatomy Expertise: Deep understanding of female reproductive anatomy, surgical approaches (vaginal, abdominal, laparoscopic, robotic), and pathophysiology.

Technical Skills & Software Knowledge

• Software Proficiency: Experience with EHR platforms common in OB/GYN (e.g., eClinicalWorks, AdvancedMD, Athenahealth, or Epic).
• Auditing Tools: Familiarity with audit management software (e.g., Audit Manager, MedTrainer, or Optum’s EncoderPro).
• Data Analysis: Ability to use Excel (pivot tables, VLOOKUPs) to track audit trends and KPI metrics.

Key Performance Indicators (KPIs)

• Audit Accuracy Rate: Maintain a 95% or higher accuracy rate for reviewed charts.
• Clean Claim Rate: Support the goal of a 95%+ clean claim rate for surgical services.
• Reduction in Denial Rate: Measurable decrease in "coding-related" surgical denials over time.
• Educational Impact: Improvement in provider documentation scores following training sessions.

Physical & Mental Requirements

• High level of concentration for long periods of reviewing complex medical text.
• Strong communication skills to handle sensitive feedback discussions with surgeons and department heads.
• Strong research skills to navigate shifting payer policies and annual code updates (e.g., CMS revisions).

PHYSICAL DEMANDS:
Note: Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions as described. Regular eye-hand coordination and manual dexterity is required to operate office equipment. The ability to perform work at a computer terminal for 6-8 hours a day and function in an environment with constant interruptions is required. At times, Team Members are subject to sitting for prolonged periods. Infrequently, Team Member must be able to lift and move material weighing up to 20 lbs. Team Member may experience elevated levels of stress during periods of increased activity and with work entailing multiple deadlines.
A job description is only intended as a guideline and is only part of the Team Member’s function. The company has reviewed this job description to ensure that the essential functions and basic duties have been included. It is not intended to be construed as an exhaustive list of all functions, responsibilities, skills and abilities. Additional functions and requirements may be assigned by supervisors as deemed appropriate.