Inpatient/Outpatient Internal Quality Reviewer

Inpatient/Outpatient Internal Quality Reviewer

Internal Quality Reviewer, Health Information Management will have the primary responsibility of being an expert resource to the Manager of Internal Quality, Lead Auditors, Fellow Auditors, Coding Work Force Managers, Education Manager and Coder staff.

This position is accountable for auditing and providing education for Inpatient and Outpatient Coders as well as Revenue Cycle Solutions Consultants and will ensure client satisfaction.

A dedicated schedule of 20 hours per week is required.

Job Responsibilities

Conducts initial pre-bill and/or onboarding reviews and monthly audits for Revenue Cycle Solutions Consultants per designated schedule.

Audits and analyzes coded data to identify aberrant coding practices that do not fall in line with established coding policies and procedures. Coordinate and provide feedback to coders and when necessary, Work Force Managers.

Continuously meets productivity expectations, per complexity indices, determined for each client specifically in the area audited.

Maintains daily schedule and covers audits for Inpatient and Outpatient Coding and assists when gaps are identified.

Proactively take action to ensure all client commitments are met.

This individual should be experienced in reviewing and breaking down complex operative reports, translating clinical documentation into accurate coding concepts, and communicating findings effectively.

Able to develop clear, well-written audit reports and provide meaningful, actionable education recommendations that help coders improve accuracy, compliance, and overall performance.

Serves as a coding and auditing resource by answering coder questions with clear educational explanations, supporting evidence, and references to applicable Official Coding Guidelines, Coding Clinic advice, CPT Assistant articles, and other authoritative resources.

Able to explain audit findings, defend recommendations with supporting rationale, and provide education that promotes coder understanding and long-term development rather than simply identifying errors.

Mentors' coders by delivering audit-based education, identifying opportunities for improvement, and partnering with leadership to support ongoing quality and compliance efforts.

Effectively explains audit findings, defend recommendations with supporting rationale, and provides education that promotes coder understanding and long-term development rather than simply identifying errors.

Collaborative, detail-oriented, and passionate about using audit insights to drive coder development, coding quality, and organizational success.

Complete all assigned audits by deadline.

Responds to management within 1 - 2 business hours, unless otherwise determined by the manager.

Responds to Coding Consultant Rebuttal responses within 24 hours for Pre-bill/Onboarding Audits and within 24 hours for Monthly Audits.

Compiles and follows through on all processes entailed in audits and client obligations.

Identifies trends in inpatient coding, as well as DRG validation and recommends focus areas for further coding education to WFM and Internal Quality Manager.

Adheres to the 'Standard Terminology for Auditor Recommendations' Policy.

Utilizes industry-recognized references to support their review findings, such as the ICD-10- CM/PCS Official Guidelines for Coding and Reporting, CPT, HCPCS, AHIMA Standards of Ethical Coding, AHIMA Practice Briefs related to compliant querying, and AHA Coding Clinics and CPT Assistant guidance.

Updates systems with all vital audit information within 24 hrs. of an audit being finalized.

Identify coding, documentation, and compliance trends that drive quality improvement initiatives.

Assists in providing client and coder assistance with coding, query writing and audit questions, as requested.

Assists in providing education to coders when audits are below 95%, as requested.

Performs miscellaneous job-related duties, as assigned.

Communicate issues as needed to Manager, Internal Quality.

Provides timely communication in response to customer-related issues, as well as any internal audit-related questions, to ensure a successful experience.

Develops and maintains supportive and positive relationships with all employees.

Education

Bachelor's Degree | Preferred | Not Required

Certifications

Certified Coding Specialist (CCS) | American Health Information Management Association (AHIMA) | OR Certified Professional Coder (CPC) | American Academy of Professional Coders (AAPC) | Required

Certified Professional Medical Auditor (CPMA) (AAPC) | Preferred

Registered Health Information Administrator (RHIA) | American Health Information Management Association (AHIMA) | Preferred

Registered Health Information Technician (RHIT) | American Health Information Management Association (AHIMA) | Preferred

Minimum Work Experience

3+ years of coding and auditing experience.

Experience with various Encoder software programs.

Basic understanding of healthcare billing/accounting systems/healthcare revenue cycle.

Understanding of physician query processes.

Key Skills

Exceptional analytical skills,

Strong attention to detail

Excellent organizational and computer technical skills.

Proficiency with MS Word, Excel, and PowerPoint.

Ability to use coding references such as (Coding Clinic, Current Procedural Terminology Assistant, etc.).

Ability to perform multiple audits and meet deadlines.

Ability to handle conflicts and offer actionable resolution

Strong communication,

Critical thinking, auditing, and educational skills are essential