Quality Analyst - Outpatient, Healthcare

EXL • United States,

13d • $85,000 - $92,000 • Remote

About The Position

EXL Health is seeking an experienced Outpatient Quality Analyst – QC Coder to perform quality reviews of outpatient coding audits. This remote, U.S.-based role validates coded data and audit decisions against medical documentation, client and program expectations, and applicable coding and payer guidance. The analyst supports consistent audit results, provides feedback and mentoring to coding auditors, identifies trends and process gaps, and contributes to training and continuous improvement. A brief coding or auditing assessment may be part of the interview process.

The role requires extensive outpatient coding knowledge, including complex services and Medicare payment and coverage policies. The analyst manages assigned quality assurance inventory while meeting quality, productivity, and turnaround expectations, and works with the Quality Manager on recurring errors and trends. EXL describes its environment as fast-paced and innovative, with mentoring, coaching, and opportunities for learning and career development.

Requirements

• Hold a CCS, CPC, or COC certification.
• Have at least 5 years of coding experience in professional or hospital coding.
• Have a thorough understanding of ICD-10-CM, HCPCS/CPT, Medicare OPPS, and APC.
• Be able to code a wide variety of complex outpatient services, such as interventional radiology, ambulatory surgery, emergency room, and observation services.
• Have expertise in Medicare Local Coverage Determinations (LCD) and National Coverage Determinations (NCD).
• Have expertise in NCCI edits, Medically Unlikely Edits (MUEs), and facility modifier application (e.g., 59/XS, 73/74, and 25) under applicable Medicare guidelines, OPPS, and ASC payment methodologies.
• Be able to write professional notes citing recognized resources, such as Official Coding Guidelines, ICD-10 Coding Handbook, AHA Coding Clinic, AHA Coding Clinic for HCPCS, CPT Assistant, and the Medicare Claims Processing Manual.
• Have excellent verbal, written, and interpersonal communication skills.
• Have strong organizational skills, attention to detail, and a high degree of accuracy.
• Be able to work in a team environment and independently as needed.
• Demonstrate flexibility and adaptability.
• Have superior coding audit and monitoring skills.
• Have excellent decision-making skills and sound judgment, including the ability to make independent decisions in varied situations.
• Have strong technical knowledge and the ability to learn new systems quickly.
• Be able to complete tasks efficiently, resolve problems, and meet deadlines.
• Be proficient in Microsoft Excel, PowerPoint, Outlook, and Word.

Nice To Haves

• CPMA, COSC, CCC, or CASCC certification.
• Prior coding audit, compliance review, RAC, or payer-side Payment Integrity audit experience.
• Experience reviewing operative reports for complex surgical procedures, including orthopedic, cardiac/vascular, and multi-specialty/general surgery procedures.

Responsibilities

• Review the accuracy and consistency of coding auditors’ work and ensure audits are appropriately marked for findings or no findings.
• Validate audit determinations, documentation support, and rationales against client and program expectations.
• Review medical records to determine whether facility coding is accurate.
• Assign root cause analysis categories, identify errors and recurring trends, and report them to the Quality Manager.
• Mentor coding auditors and provide feedback as needed.
• Perform quality reviews of initial audits and appeals.
• Manage assigned QA inventory and meet quality, productivity, and turnaround expectations.
• Identify overpayment and underpayment findings, including opportunities outside the audit concept, and support audit reporting and trend analysis.
• Participate in calibration sessions to promote consistent review decisions, rationale documentation, and application of coding and payer guidance.
• Recommend process changes to improve quality and performance.
• Escalate recurring errors, guideline questions, or process gaps to the Quality Manager.
• Stay current on CMS, payer, LCD/NCD, NCCI, OPPS/APC, CPT, HCPCS, modifier, and ICD-10-CM updates and apply them consistently in quality reviews.
• Perform other duties as assigned.
• Conduct job functions in accordance with company compliance, information security, and regulatory policies, procedures, and programs.

Benefits

• Mentoring program assigning junior-level employees a senior-level professional advisor.
• Guidance and coaching for employees.
• Opportunities for learning, growth, and career development.

What This Job Offers

• Job Type: Full-time
• Career Level: Senior
• Education Level: No Education Listed