Quality Validation Specialist, Outpatient Coding

The role

The Quality Validation Specialist reviews completed outpatient coding validation audits to ensure accuracy and compliance. This role evaluates audit quality for various coding types and provides feedback and education to auditors.

What you will do

• Performs secondary reviews of completed outpatient coding validation audits.
• Evaluates auditor performance against quality and accuracy benchmarks.
• Provides detailed, constructive feedback and coaching to auditors.
• Develops, maintains, and enhances quality assurance tools and documentation standards.
• Collaborates with leadership to improve audit methodologies and support quality improvement.
• Validates accurate assignment of CPT, HCPCS Level II, and ICD-10-CM codes.
• Monitors and reports QA metrics, audit findings, and quality trends to leadership.
• Maintains knowledge of outpatient reimbursement methodologies and regulatory updates.
• Ensures adherence to ethical coding and auditing standards.
• Assists with development and delivery of training materials and educational resources.

Required qualifications

• Current certification through AHIMA and/or AAPC, including one or more of the following: RHIA, CCS, or CPC.
• 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.
• Ability to work independently and collaboratively in a fast-paced production and quality-driven environment.

Nice to have

• Associate’s or Bachelor’s degree in Health Information Management, Healthcare Administration, or a related field
• 5–7 years of experience performing pre-pay, post-pay, and/or post-adjudication outpatient validation reviews related to OPPS/APC reimbursement
• Advanced experience auditing or coding complex outpatient facility claims including Interventional Radiology, Radiation Oncology, Behavioral Health, Ambulatory Surgery, Cardiac Catheterization, Implan
• Experience coding, auditing, or validating Enhanced Ambulatory Patient Grouping (EAPG) claims
• Prior quality assurance, auditor mentoring, training, or team lead experience

Benefits

• PTO
• Paid Holidays
• Volunteer Days
• Eligibility for health, vision and dental coverage
• 401(k) plan participation with company match
• Flexible spending accounts
• Tuition Reimbursement
• Company-paid life insurance
• Company-paid short-term disability
• Company-paid parental leave

About the company

Machinify is a healthcare intelligence company that delivers value, transparency, and efficiency to health plan clients using an AI-powered platform.