Senior Coding Quality Analyst

Minimum Qualifications

• High school diploma or equivalent required; a four-year degree in Health Information Management, Healthcare Administration, Business, Finance, Nursing, or a related field preferred.
• Minimum of 7 years of relevant experience in professional fee coding, coding audit, billing compliance, reimbursement, healthcare operations, or related revenue cycle functions.
• Minimum of 3 years of professional fee coding audit or complex coding review experience.
• Experience independently reviewing medical records, determining findings, researching coding or payer guidance, documenting conclusions, and communicating findings to leadership or stakeholders.
• Demonstrated experience conducting investigations, root-cause analysis, validating findings, preparing written reports, coordinating with cross-functional stakeholders, and tracking issues through resolution.
• Experience reviewing multiple professional fee specialties; oncology, infusion, surgery, radiation oncology, and evaluation and management services preferred.
• Strong knowledge of CPT, HCPCS, ICD-10-CM, evaluation and management services, modifiers, medical necessity, provider documentation requirements, payer billing requirements, CMS guidance, NCCI edits, LCDs, NCDs, and professional fee reimbursement.
• Experience with coding and billing systems, electronic medical records, practice management systems, claim information, data analysis, and operational workflows.
• Experience supporting government, regulatory, payer, risk-based, focused, validation, or other complex reviews preferred.

Licenses and Certifications

• Current professional coding certification required: CPC, CCS-P, COC, RHIA, or RHIT.
• Current auditing credential required: CPMA, CHA, or an equivalent nationally recognized healthcare coding audit credential approved by the organization.
• Candidates with CPC, CCS-P, or COC must also hold an active auditing credential.
• Credentials must be active and in good standing at the time of hire and maintained throughout employment.

Skills

• Ability to evaluate issues from coding, documentation, billing, reimbursement, system, workflow, operational, quality, and compliance-risk perspectives.
• Strong analytical, investigative, organizational, critical-thinking, written communication, verbal communication, follow-up, and problem-solving skills.
• Strong attention to detail.
• Ability to work independently, manage competing priorities, and adjust work based on organizational needs.
• Proficiency with Microsoft Outlook, Word, Excel, and PowerPoint required.
• Experience with Power BI, Microsoft Lists, Access, audit software, EHRs, practice management systems, claims systems, or reporting tools preferred.