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.

ED PRO & FACILITY:

Job Summary

The ED & Pro Facility Auditor performs complex audits on high-volume emergency encounters to ensure that Evaluation and Management (E/M) levels, procedures, and diagnoses are correctly reported. They identify revenue leakage, prevent over-coding (compliance risk), and serve as the primary educator for both the coding team and ED physicians.

Key Responsibilities

1. Dual-Scope Auditing

• Professional Fee (ProFee) Audit: Review physician documentation to ensure E/M levels (99281–99285) are supported by Medical Decision Making (MDM) or time. Verify that professional procedures (e.g., intubation, laceration repair) are correctly coded with appropriate modifiers.
• Facility Audit: Audit the "technical" component of the visit. Ensure the facility E/M level accurately reflects hospital resource consumption (nursing interventions, room usage, and supplies) based on the facility’s specific leveling guidelines (e.g., ACEP or AHA models).
• Charging Integrity: Verify that facility charges (IV infusions, injections, labs, and imaging) are captured and not duplicated in the E/M level.

2. Compliance & Quality Control

• Root Cause Analysis: Investigate why "mismatches" occur between Pro and Facility levels (e.g., a Level 5 ProFee paired with a Level 2 Facility fee) and correct documentation gaps.
• Pre-Billing & Retrospective Reviews: Conduct "shadow" audits before claims drop to ensure "clean claim" submission and perform retrospective reviews to identify systemic errors.
• Regulatory Monitoring: Stay current with Medicare Outpatient Prospective Payment System (OPPS) updates and National Correct Coding Initiative (NCCI) edits.

3. Provider & Coder Education

• Feedback Loops: Provide one-on-one coaching to physicians on documenting "medical necessity" and "acuity" to support higher-level codes.
• Training: Develop and deliver training modules for ED coders specifically on the nuances of ED-specific modifiers (e.g., -25 for significant, separately identifiable services).

Technical Skills & Frameworks

• MDM Mastery: Expert knowledge of the 2021/2023 E/M guidelines, focusing on the three elements of MDM: Number/Complexity of Problems, Data Reviewed, and Risk.
• Facility Leveling Models: Deep understanding of the ACEP (American College of Emergency Physicians) point system or other internal resource-based leveling grids
• Claim Forms: Proficiency in both CMS-1500 (Professional) and UB-04 (Institutional/Facility) requirements.
• Software Proficiency: Experience with audit software (e.g., MDaudit, RevPoint) and EHRs like Epic (ASAP module) or Cerner.

Qualifications

• Experience: 3–5 years of specialized ED coding experience, with at least 2 years in an auditing or lead role.
• Certifications (Required):
  • AAPC: CPC (Professional) AND COC (Outpatient Outpatient) or CEDC (Emergency Department).
  • AHIMA: CCS or CCS-P.
• Preferred Certification: CPMA (Certified Professional Medical Auditor) is highly preferred for this role.
• Education: Associate’s or Bachelor’s degree in life sciences

Key Performance Indicators (KPIs)

• Coding Accuracy Rate: Maintain a minimum 95% accuracy rate for both Pro and Facility audits.
• Level Distribution: Monitor "Bell Curve" trends to ensure the facility is not an outlier compared to national averages (preventing RAC audits).
• Denial Reduction: Percentage reduction in ED-related medical necessity and bundling denials.
• Mismatch Rate: Reducing the frequency of unsupported discrepancies between Professional and Facility service levels.

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.