Lead Associate, Outpatient Coding Quality Auditor

🔥 16 hours ago

🤠 Texas – Remote

🤠 Texas – Remote

💵 $60.1k - $85.8k / year

⏰ Full Time

🟠 Senior

🔎 Auditor

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Gainwell Technologies

WebsiteLinkedInAll Job Openings

10,000+ employees

💼 Consulting

📦 Logistics

⚕️ Healthcare Insurance

💰 Grant on 2023-06

Consulting • Logistics • Healthcare Insurance

Gainwell Technologies is the nation’s leading provider of digital and cloud-enabled solutions across the human services and public health ecosystem. With a mission-driven approach, Gainwell serves clients in all 50 U. S. states, focusing on improving health outcomes and delivering intuitive, human-centered experiences. Their comprehensive suite of solutions includes Medicaid Enterprise modernization, data analytics, provider services, and pharmacy solutions, all designed to advance the future of healthcare and enhance community well-being.

📋 Description

• Conduct detailed reviews of medical records, claims, and supporting documentation to determine the accuracy and appropriateness of assigned ICD-10-CM, CPT, HCPCS Level II, and modifiers • Apply contract-specific review methodologies to identify coding discrepancies, billing errors, reimbursement inaccuracies, and compliance concerns • Evaluate documentation to ensure coding assignments are supported and compliant with applicable regulatory and payer requirements • Accurately document audit findings, rationale, and recommendations using proprietary audit and case management systems • Provide comprehensive coding and reimbursement determinations supported by clinical documentation, coding guidelines, payment methodologies, and regulatory requirements • Perform ongoing quality assurance audits of coding and clinical review staff • Interpret and apply official coding guidelines, CMS regulations, NCCI edits, OPPS requirements, EAPG methodologies, APC payment policies, and ASC reimbursement guidelines • Assess auditor and reviewer performance against quality benchmarks and productivity standards • Identify process improvement opportunities and recommend corrective actions • Participate in inter-rater reliability activities and quality calibration sessions • Assist in developing quality monitoring processes, audit tools, and review protocols • Serve as a subject matter expert on outpatient coding, reimbursement methodologies, and payment integrity principles • Achieve productivity and quality performance standards established by management

🎯 Requirements

• One or more active professional credentials through AHIMA or AAPC: CPC, COC, CCS, RHIA, RHIT; required • 3+ years experience in outpatient medical record coding required • 3+ years of coding auditing, quality assurance, or coding validation experience required • Extensive experience reviewing outpatient facility claims and medical records • Demonstrated expertise in outpatient reimbursement methodologies, including Enhanced Ambulatory Patient Groups (EAPG), Ambulatory Payment Classifications (APC), and Ambulatory Surgery Center (ASC) payment systems • Experience performing payment integrity, compliance, or reimbursement-focused audits preferred • Experience leading quality initiatives, training staff, or serving as a coding subject matter expert preferred • Remote position within the United States

🏖️ Benefits

• Benefits available starting on the first day of employment • Clear career advancement opportunities through training and leadership development • Flexible work hours • Work flexibility, learning, and career development • Generous, flexible vacation policy • 401(k) employer match • Comprehensive health benefits • Educational assistance • Leadership and technical development academies