Quality Validation Specialist

🔥 4 minutes ago

🇺🇸 United States – Remote

💵 $105k / year

⏰ Full Time

🟡 Mid-level

🟠 Senior

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Machinify

WebsiteLinkedInAll Job Openings

1001 - 5000 employees

⚕️ Healthcare Insurance

🤖 Artificial Intelligence

☁️ SaaS

💰 $10M Series A - Machinify on 2018-10

Healthcare Insurance • Artificial Intelligence • SaaS

Machinify is a healthcare-focused AI platform and services company that reshapes healthcare payments and payment integrity. Its AI operating system unifies claims, medical records, contracts, and policies, and uses foundation models and task-specific agents to automate and improve coding, payment accuracy, recoveries, and cost avoidance. Machinify serves health plans (including 18 of the top 20), supports insourced, hybrid, or fully-managed deployments, and emphasizes measurable outcomes — reporting 85+ customers, 270M member lives covered, and $6B+ in annual cost avoidance and recoveries.

📋 Description

• Performs secondary reviews of completed outpatient coding validation audits to verify coding accuracy, supporting rationale, and compliance with official coding guidelines, payer policies, reimbursement methodologies, and internal audit standards. • Evaluates auditor performance against established quality and accuracy benchmarks, identifying trends, educational opportunities, and areas requiring corrective action. • Provides detailed, constructive feedback and coaching to auditors to promote consistency, accuracy, and appropriate interpretation and application of coding and billing guidelines. • Develops, maintains, and enhances quality assurance tools, scorecards, audit tracking mechanisms, and documentation standards to support objective and consistent review processes. • Collaborates with leadership and operational teams to improve audit methodologies, clarify coding guidance, standardize processes, and support continuous quality improvement initiatives. • Validates accurate assignment and review of CPT, HCPCS Level II, and ICD-10-CM codes, including appropriate use of modifiers and supporting references such as Official Coding Guidelines, CMS regulations, AMA guidance, LCDs, and NCDs. • Develops and maintains QA tools, scorecards, and documentation standards to support objective review processes. • Monitors and reports QA metrics, audit findings, quality trends, and corrective action plans to leadership for performance oversight and operational improvement. • Maintains current knowledge of outpatient reimbursement methodologies, regulatory updates, coding changes, and industry standards related to Medicare OPPS, APCs, and EAPGs. • Ensures adherence to ethical coding and auditing standards established by AHIMA, AAPC, CMS, and organizational compliance policies. • Performs secondary reviews across multiple audit and coding platforms while maintaining established productivity and quality expectations. • Assists with development and delivery of training materials and educational resources related to identified trends, coding updates, policy changes, and performance improvement opportunities. • Participates in calibration sessions and quality consistency initiatives to ensure standardized audit interpretation and scoring methodologies. • Performs other duties as assigned.

🎯 Requirements

• Associate’s or Bachelor’s degree in Health Information Management, Healthcare Administration, or a related field preferred. • Current certification through AHIMA and/or AAPC required, including one or more of the following: • RHIA (Registered Health Information Administrator) • CCS (Certified Coding Specialist) • CPC (Certified Professional Coder) • Minimum of 5 years of hospital outpatient coding experience within OPPS reimbursement methodologies and/or at least 5 years of outpatient/APC validation auditing experience. • Extensive knowledge of CPT, HCPCS Level II, ICD-10-CM, NCCI edits, and appropriate modifier usage. • Strong understanding of Medicare Outpatient Prospective Payment System (OPPS), Ambulatory Payment Classifications (APCs), and outpatient reimbursement methodologies. • Proficiency interpreting and applying Medicare LCD and NCD guidelines. • Experience using industry-standard encoder and auditing tools such as Optum, TrueBridge, and/or 3M. • Demonstrated ability to review and validate a broad range of outpatient facility services and claim types. • Strong analytical, critical thinking, organizational, and problem-solving skills. • Excellent verbal and written communication skills with the ability to provide clear, professional feedback and education. • Ability to work independently and collaboratively in a fast-paced production and quality-driven environment.

🏖️ Benefits

• PTO, Paid Holidays, and Volunteer Days • Eligibility for health, vision and dental coverage, 401(k) plan participation with company match, and flexible spending accounts • Tuition Reimbursement • Eligibility for company-paid benefits including life insurance, short-term disability, and parental leave. • Remote and hybrid work options