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.

Speciality of the QA needed for this job is Pro/Ed facility & Urgent care

The ED Facility Medical Coder ensures the accurate and timely assignment of ICD-10-CM, CPT, and HCPCS codes for all emergency room encounters. This role is critical to the hospital s Revenue Cycle Management (RCM), as it determines the facility s reimbursement based on the "intensity of resources" used during a patient s visit.

1. Medical Record Review & Abstracting

• Analyze clinical documentation, including nursing notes, triage reports, physician assessments, and discharge summaries, to identify all billable services.
• Abstract key data points such as admission/discharge dates, patient disposition, and trauma-related details.

2. Facility-Level E/M Assignment

• Assign Evaluation and Management (E/M) levels (CPT [phone removed]) based on facility-specific leveling guidelines (e.g., the ACEP point system or staff intervention models).
• Evaluate resource consumption (e.g., nursing time, supplies, and number of diagnostic tests) to justify the appropriate facility level.

3. Infusion, Injection & Procedural Coding[ 1 ][ 2 ][ 3 ][ 4 ]

• Apply the Infusion Hierarchy for facility reporting: Chemotherapy > Therapeutic / Prophylactic / Diagnostic > Hydration.[ 5 ][ 6 ][ 7 ]
• Assign codes for specialized ED procedures, such as laceration repairs, splinting, intubation, and central line insertions.
• Accurately report "start" and "stop" times for infusions to capture the correct initial and sequential units.

4. Compliance & Quality Assurance

• Ensure all coding follows National Correct Coding Initiative (NCCI) edits and payer-specific policies.
• Append appropriate modifiers (e.g., -25, -59, -X{EPSU}) to avoid unbundling and ensure clean claim submission.
• Identify and report documentation deficiencies to clinical staff to improve Documentation Integrity (CDI).

• Education: Related life-science field.
• Certifications (One or more required):COC (Certified Outpatient Coder) - Preferred for facility-specific roles. CPC (Certified Professional Coder)CCS (Certified Coding Specialist)CEDC (Certified Emergency Department Coder) - Specialty credential.
• Experience: 1-3 years of experience in Emergency Department or Outpatient coding.
• Technical Knowledge:Proficiency in ICD-10-CM, CPT, and HCPCS Level II code sets.Deep understanding of APC (Ambulatory Payment Classifications) and the Outpatient Prospective Payment System (OPPS).Familiarity with EHR systems like Epic (Healthy Planet/Revenue Cycle), Cerner, or 3M CodeFinder.

• Audit Readiness: Ability to support internal/external audits focusing on "E/M Upcoding" and "Unbundling of Services."
• Critical Care Coding: Mastery of the 30-minute time requirement and documentation nuances for facility critical care (99291).
• Automation Knowledge: Familiarity with Computer-Assisted Coding (CAC) and how AI-driven suggestions integrate into the workflow.

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.