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.

Summary for a Job Profile / Resume:

"Highly analytical Medical Coding Auditor with 5+ years of experience specializing in the intersection of Facility E/M and HEDIS quality metrics. Expert in navigating the 2026 CMS transition to MDM-driven facility alignment and the ICD-11 cluster coding framework. Proven track record in reducing denial rates by 20% through AI-assisted pre-billing audits and improving HEDIS Star Ratings through meticulous medical record abstraction and supplemental data validation."

As of 2026, a Medical Coding Auditor with E/M Facility and HEDIS knowledge represents a high-level specialist role in the Healthcare Revenue Cycle. This professional bridges the gap between revenue integrity (ensuring correct payment for facility resources and physician work) and quality reporting (ensuring clinical data accurately reflects patient outcomes for HEDIS).

1. Evaluation & Management (E/M) Expertise: Professional vs. Facility

In 2026, auditors must manage the "Dual-Track" nature of E/M coding, where the same patient encounter generates two different types of claims based on different criteria.

• Professional Fee (ProFee) Auditing:
  • Basis: Level selection is driven by Medical Decision Making (MDM) or Total Time on the date of the encounter
  • 2026 Standards: Auditors focus on the "Substantive Portion" in split/shared visits and the appropriate use of the G2211 complexity add-on code, which CMS expanded in 2026 to include home and residence services.
  • Focus: Verification of cognitive labor, complexity of problems addressed, and risk
• Facility Fee Auditing (Hospital Outpatient/ED):
  • Basis: Level selection is driven by Resource Intensity (nursing time, supplies, and room usage) rather than the physician's MDM.
  • 2026 Standards: While CMS still allows facilities to develop their own internal point systems, 2026 guidelines require these systems to "reasonably relate" to the intensity of hospital resources.
  • Focus: Auditing for "Charge Capture"—ensuring that interventions like IV infusions, injections, and specialized monitoring are not "unbundled" but accurately reflected in the facility E/M level (UB-04 claim).

2. HEDIS Knowledge (Measurement Year 2026)

HEDIS (Healthcare Effectiveness Data and Information Set) has shifted toward digital-first reporting in 2026. A coding auditor's role is critical in "closing gaps" through accurate code assignment.

• Key 2026 Measures for Auditors:
  • Acute Hospitalizations Following Outpatient Surgery (HFO/HFG/HFC/HFU): New for 2026, these measures track unplanned hospitalizations within 15 days of outpatient orthopedic, general, colonoscopy, or urologic surgeries. Auditors must ensure that complications and follow-up visits are coded with high specificity to accurately reflect these metrics.
  • Social Need Screening (SNS-E): In 2026, auditors must verify the use of Z-codes (Z55–Z65) to document Social Determinants of Health (SDOH), as these are now integrated into HEDIS value sets.
• Abstraction & Hybrid Reviews: In 2026, the transition to ECDS (Electronic Clinical Data Systems) means auditors spend less time on manual paper abstraction and more time auditing the FHIR-based data feeds to ensure that "Supplemental Data" (codes that didn't make it onto the original claim) are valid and supported by medical records.

3. Advanced 2026 Competencies

• ICD-11 & Cluster Coding: 2026 is a major transition year for ICD-11 adoption. Auditors must understand "Post-coordination" (building complex codes using stem and extension codes) to describe laterality, severity, and causality—all of which impact both reimbursement and HEDIS risk-adjustment.
• Linking E/M audits to HCC captures ensures that the patient's "Risk Score" is accurate, which directly influences HEDIS performance and Value-Based Care (VBC) reimbursement.

4. Required Certifications & Skills (2026)

To be competitive in this niche, a professional typically holds multiple credentials:

• Core Coding: CPC (AAPC) or CCS/CCS-P (AHIMA).
• Auditing Specific: CPMA (Certified Professional Medical Auditor) or CHCAF (Certified Healthcare Chart Auditor - Facility).
• Technical Skills: Proficiency in EHRs (Epic, Cerner), Audit software (RevInt, 3M),

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.