Outpatient (OP) QA Coder Auditor

R1 RCM PHILIPPINES, INC. is seeking an experienced Multi-Specialty Quality Reviewer to join our Cebu team. This is a full-time position where you will be responsible for conducting internal quality reviews across different medical coding specialties to assess coder performance and coding accuracy.

Responsibilities

• Conduct audits in various medical coding specialties in outpatient professional settings to assess coding accuracy and ensure adherence to official coding guidelines.

• Provide detailed rationale and supporting references for recommendations and findings.

• Utilize industry-recognized references to support review findings, such as the ICD10-CM Official Guidelines for Coding and Reporting, AHIMA Standards of Ethical Coding, AHIMA Practice Briefs related to compliant querying, and AHA Coding Clinic, and AMA CPT Assistant.

• Identify coding error trends across multiple specialties to aid in root cause analysis.

• Stay current with updates in medical coding guidelines, payer-specific requirements, and client-specific requirements.

• Prepare and present reports summarizing audit findings and error trends.

• Identify smart observations for process improvements with quantifiable business impact.

• Calibration sessions between Operations, Quality, and Training to ensure knowledge alignment with client needs and specifications.

• Calibration sessions between processes such as Back-end and Middle Coding.

• Adhere to HIPAA regulations and uphold a high standard of privacy and confidentiality.

• Adhere to all policies and procedures to ensure an efficient workflow process.

• Researching, escalating, and responding to auditor support questions as

triaged by leadership.

• Other duties as assigned by leadership (special projects, assessments, etc.).

Required Qualifications

• Bachelor's degree in a medical allied course is preferred. For other courses, a high level of knowledge and relevant work experience to illustrate capability
• More than 2 years in the associate position (e.g., Medical Coding / Billing Review).
• At least 5 years of total work experience in medical coding for outpatient professional settings with exposure to multiple specialties.
• At least 1 year experience in each specialty with a minimum of 2 specialties – Same Day Surgery, Observation, Interventional Radiology, Oncology, Transplant, OBGYNE, Emergency.
• Currently holds and maintains at least 1 role-related certification (CPC, COC, CCS, CCS-P for outpatient roles, CPMA for auditing role).
• Strong knowledge of CMS guidelines, Ambulatory Payment Classification (APC), Outpatient Prospective Payment System (OPPS), and National Correct Coding Initiative (NCCI) edits.
• Experience working with coding software such as Epic, Cerner, Meditech, and 3M 360.

Good to have Qualifications

• Additional certifications in specific specialties (CEMC, CASCC, CEDC, CGSC, CHONC, CIRCC, COBGC for specialty roles, CPMA for auditing role) are a plus.
• Experience in professional coding is a plus.
• At least 1 year of experience as a quality auditor is preferred.
• Excellent communication skills, presentation skills, and proficiency in MS Excel & PowerPoint.
• Proficiency in medical terminologies and disease processes.

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