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:

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.

Key Responsibilities

1. 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.

2. 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.

3. 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.

4. 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.

5. 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.

6. 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, Meditech) and Revenue Cycle software (e.g., Waystar, Availity, nThrive).

• Communication: Ability to explain complex coding/billing concepts to non-coding staff and physicians.

Education & Experience Requirements

• Education: Associate’s or Bachelor’s degree in Health Information Management (HIM), Healthcare Administration, or a related field preferred.

• Experience: Minimum of 3–5 years of medical coding experience, specifically focusing on denials, audits, or revenue cycle analysis.

• Required Certifications (at least one of the following):

  • CPC (Certified Professional Coder) – AAPC

  • CCS (Certified Coding Specialist) – AHIMA

• 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.

Physical Demands & Work Environment

• Remote or office-based environment.

• Extensive computer use and prolonged sitting.

• Must be able to manage high volumes of data with extreme attention to detail.

Performance Indicators (KPIs) for this Role

• Clean Claim Rate (CCR): Percentage of claims passing edits on the first pass.

• Denial Rate: Reduction in coding-related denials over time.

• Days in A/R: Contribution to lowering the time it takes to collect payments.

• Audit Accuracy: Maintaining a 95% or higher accuracy rate during internal/external audits.

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.