Role Overview
The Quality Assurance (QA) Specialist – Medical Coding evaluates, audits, and maintains the accuracy, integrity, and regulatory compliance of medical coding across patient records and billing claims. This role conducts systematic pre- and post-bill audits to verify proper assignment of ICD-10-CM/PCS, CPT, and HCPCS codes in accordance with official coding guidelines, CMS regulations, and payer requirements. The QA Specialist collaborates with coding staff, revenue cycle teams, and Clinical Documentation Improvement (CDI) specialists to address error trends, deliver targeted education, and mitigate compliance risks.
Key ResponsibilitiesCoding Audits & Quality Monitoring
- Systematic Chart Audits: Conduct regular and ad-hoc quality assurance audits on inpatient, outpatient, and professional fee coding to ensure code selection, modifier application, and DRG/APC assignments meet designated accuracy thresholds (e.g., 95%+).
- Documentation Verification: Evaluate provider clinical documentation to verify that coded diagnoses and procedures are fully supported by medical record entries.
- Denials & Rejection Review: Analyze coding-related claim denials, medical necessity rejections, and NCCI (National Correct Coding Initiative) edits to identify systemic documentation or coding errors.
Compliance & Regulatory Adherence
- Regulatory Alignment: Maintain strict adherence to official coding guidelines (AAPC/AHIMA standards), CMS regulations, OIG compliance directives, and HIPAA/PHI privacy mandates.
- Policy Updates: Track quarterly and annual code revisions (ICD-10, CPT, HCPCS) and update internal audit tools, checklists, and reference guides accordingly.
Feedback, Analytics & Training
- Root-Cause Analysis: Identify recurring coding errors, documentation gaps, and risk areas through structured data analysis and trend reporting.
- Coder Coaching & Education: Provide constructive, objective feedback to coding staff; develop and conduct targeted group or one-on-one training sessions to remediate identified audit findings.
- Audit Reporting: Prepare and present detailed QA performance metrics, accuracy rates, and corrective action plans to HIM management and revenue cycle leadership.
Qualifications & RequirementsRequired Experience & Education
- Experience: Minimum of 3–5 years of hands-on medical coding experience (inpatient or outpatient), plus at least 1–2 years in a dedicated coding audit, quality assurance, or educator role.
- Active Certification (Must hold at least one):
- Certified Professional Coder (CPC)
- Certified Coding Specialist (CCS / CCS-P)
- Certified Professional Medical Auditor (CPMA)
- Registered Health Information Administrator/Technician (RHIA / RHIT)
Technical Skills & Knowledge
- Coding Systems: Expert-level mastery of ICD-10-CM/PCS, CPT, HCPCS Level II, NCCI edits, E/M coding guidelines, and DRG/APC grouping methodologies.
- Software & EHR Systems: Proficiency with major Electronic Health Record (EHR) systems (e.g., Epic, Cerner) and automated encoder software (e.g., 3M, Optum).
- Data Analysis: Practical skill in using audit management tools and Microsoft Excel (pivot tables, reporting) to track and analyze coding accuracy trends.
Core Competencies
- Precision & Detail: Exceptional thoroughness in examining clinical records and verifying complex coding rules.
- Analytical Thinking: Capability to synthesize audit findings into meaningful, actionable insights for process improvement.
- Constructive Communication: Strong written and verbal communication skills required to deliver diplomatic, clear feedback to coders and clinical documentation staff.
- Compliance Integrity: Uncompromising commitment to ethical coding practices, regulatory standards, and patient data confidentiality.
Pay: ₹25,000.00 - ₹40,000.00 per month
Benefits:
- Health insurance
- Leave encashment
- Life insurance
- Provident Fund
Work Location: In person
