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.

A Medical Coding Denial Quality Analyst is a specialized professional within the Revenue Cycle Management (RCM) department.

Their primary goal is to bridge the gap between medical coding accuracy and financial reimbursement by investigating why claims are denied and ensuring the quality of future coding to prevent recurrence.

Below is a comprehensive job description for this role.

Job Summary

The Medical Coding Denial Quality Analyst is responsible for auditing denied medical claims, identifying root causes for rejections, and coordinating the appeals process.  This role combines clinical knowledge, coding expertise (ICD-10, CPT, HCPCS), and data analysis to ensure coding compliance and maximize revenue. The analyst also provides education and feedback to the coding and clinical teams to improve overall documentation and claim accuracy.

Key Responsibilities

1. Denial Investigation & Management

• Root Cause Analysis (RCA): Analyze denied claims to identify specific reasons for rejection (e.g., lack of medical necessity, bundling issues, incorrect modifiers, or clinical documentation gaps).
• Appeals Management: Prepare, draft, and submit formal appeal letters to insurance payers, including clinical evidence and coding guidelines to support the case.
• Trend Tracking: Monitor and categorize denial trends by payer, specialty, or coder to identify systemic issues.

2. Quality Assurance & Auditing

• Claim Auditing: Perform retrospective and prospective audits of coded records to ensure they meet federal, state, and payer-specific guidelines.
• Accuracy Benchmarking: Ensure that the coding team maintains a high accuracy standard (typically 95% or higher).
• Compliance: Verify that all coding adheres to HIPAA standards and Official Coding Guidelines (AAPC/AHIMA).

3. Education & Feedback Loop

• Coder Education: Develop training materials and conduct one-on-one or group sessions for coders based on denial trends and audit findings.
• Physician Queries: Work with clinical staff to improve documentation when "lack of specificity" is a recurring cause for denials.
• Process Improvement: Recommend workflow changes or system edits to catch potential errors before a claim is submitted.

4. Reporting & Analytics

• Generate weekly/monthly reports on denial rates, recovery amounts, and quality scores.
• Maintain "QA Dashboards" to present findings to RCM leadership.

Qualifications & Requirements

Education & Experience

• Education: Bachelor’s degree.
• Experience: 3–5 years of active medical coding experience across multiple specialties (e.g., 3 years denial management or quality auditing.
•  

Mandatory Certifications

Professional certification from AAPC or AHIMA is typically required:

• CPC (Certified Professional Coder)
• CCS (Certified Coding Specialist)[
• CPMA (Certified Professional Medical Auditor) — highly preferred for quality roles.

Technical Skills

• Coding Systems: Mastery of ICD-10-CM, ICD-10-PCS, CPT, and HCPCS Level II.
• Regulatory Knowledge: Deep understanding of NCCI (National Correct Coding Initiative) edits, MUEs (Medically Unlikely Edits), and CMS guidelines.[8]
• Software Proficiency:
  • EHR/EMR Systems: (e.g., Epic, Cerner, Meditech).
  • Encoding Tools: (e.g., 3M, EncoderPro).
  • Data Tools: Advanced MS Excel (Pivot tables, VLOOKUPs) for trend analysis.

Core Competencies

• Analytical Thinking: Ability to look at a complex denial and "reverse engineer" the error.
• Attention to Detail: Noticing minor discrepancies in documentation that could lead to a large-scale denial.
• Communication: Ability to explain complex coding rules to non-coding staff and write persuasive appeals to payers.
• Problem Solving: Developing long-term solutions rather than just "fixing" a single claim.

Common Performance Metrics (KPIs)

• Clean Claim Rate (CCR): Percentage of claims that pass without a denial.
• Denial Overturn Rate: Success rate of appeals submitted.
• Audit Accuracy Score: The percentage of audited charts found to be correctly coded.
• Days in AR: Reducing the time it takes to get paid by resolving denials faster.

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.