What does the Coding Quality Analyst Do
Under minimal supervision, performs comprehensive reviews and investigations involving coding, documentation, billing, reimbursement, systems, workflows, and operational processes. Reviews may originate within Coding Operations or from business partners and organizational stakeholders requiring coding and operational expertise. Evaluates concerns from all applicable perspectives to determine the root cause, scope, impact, and appropriate resolution. Determines whether identified concerns are related to coding, documentation, billing, system configuration, workflow, process design, staff or provider education, operational practices, payer requirements, or a combination of factors. Conducts audits, investigative research, data validation, claim review, and medical record review before issuing findings or recommendations. Coordinates with Coding Operations, Audit Operations, Education, Operations, Revenue Cycle, Information Technology, Compliance, reimbursement, clinical leadership, and other departments as necessary to obtain complete information and resolve identified issues. Tracks findings, recommendations, and corrective actions through completion. Validates that corrective actions effectively resolved the identified issue and communicates final outcomes to the appropriate stakeholders. Supports and adheres to the US Oncology Compliance Program, including the Code of Ethics and Business Standards.
Responsibilities
ESSENTIAL DUTIES AND RESPONSIBILITIES
Performs complex reviews and investigations involving coding, documentation, billing, reimbursement, systems, workflows, operational processes, and related quality concerns.
Receives and evaluates review requests originating within Coding Operations or from organizational stakeholders requiring coding and operational expertise.
Establishes the appropriate scope and review methodology based on the reported concern, potential risk, available information, and affected services or processes.
Reviews medical records, provider documentation, coding, charges, claims, billing activity, system configuration, operational workflows, policies, procedures, and supporting data to determine the facts and circumstances related to each concern.
Evaluates concerns from all applicable perspectives and does not limit the investigation to the initially reported issue or assumed cause.
Determines whether the identified issue is related to coding, documentation, billing, reimbursement, payer requirements, system configuration, workflow, process design, training, staff activity, provider activity, or a combination of factors.
Conducts focused audits, medical record reviews, claim reviews, data validation, coding validation, and other investigative activities necessary to confirm the concern and determine its scope.
Researches applicable CPT, HCPCS, ICD-10-CM, CMS, Medicare Administrative Contractor, National Correct Coding Initiative, payer, regulatory, and organizational guidance.
Distinguishes between the reported concern, validated finding, contributing factors, and root cause before communicating conclusions.
Identifies the population, time frame, specialties, providers, locations, claims, charges, or workflows potentially affected by the issue.
Assesses the potential coding, documentation, billing, reimbursement, operational, financial, and compliance impact of validated findings.
Documents the concern received, investigative steps completed, evidence reviewed, findings, root cause, scope, impact, and recommended actions.
Ensures conclusions and recommendations are supported by medical record documentation, data, authoritative guidance, system evidence, workflow validation, or other appropriate supporting information.
Prepares clear and concise reports of findings and recommendations for Coding leadership and other appropriate stakeholders.
Identifies patterns, trends, control weaknesses, system issues, documentation deficiencies, coding concerns, billing risks, workflow barriers, and recurring operational problems.
Determines when additional departments or subject-matter experts must be involved and coordinates their participation in the review.
Collaborates with Coding Operations, Audit Operations, Education, Operations, Revenue Cycle, Information Technology, Compliance, reimbursement, clinical leadership, providers, and other stakeholders to validate findings and determine appropriate next steps.
Facilitates communication among involved stakeholders to clarify responsibilities, address dependencies, and prevent gaps in issue resolution.
Develops or recommends corrective actions based on the validated root cause, identified risk, and affected process.
Documents responsible owners, required actions, expected deliverables, and target completion dates based on leadership direction and the outcome of the review.
Tracks corrective actions, process changes, system corrections, coding updates, education, rebilling activities, workflow changes, and other remediation efforts through completion.
Follows up with responsible stakeholders regarding outstanding actions, unresolved concerns, and missed completion dates.
Performs follow-up reviews to validate that corrective actions were implemented and effectively resolved the identified issue.
Determines whether additional monitoring, education, auditing, system controls, or process changes are necessary to reduce the risk of recurrence.
Escalates significant findings, potential risk, recurring issues, unresolved concerns, ineffective corrective actions, and missed remediation commitments to the appropriate leadership.
Communicates final findings, actions taken, validation results, remaining risk, and closure status to the appropriate stakeholders.
Ensures reviews are not closed until required actions have been completed, resolution has been validated, and the final outcome has been documented.
Develops and maintains standardized review procedures, investigation tools, tracking methods, documentation requirements, report templates, and closure criteria.
Recommends procedural improvements, system controls, workflow changes, monitoring activities, audit opportunities, and education based on review findings.
Supports implementation of approved process improvements and monitors whether changes produce the intended result.
Serves as a Coding Operations resource regarding professional coding, documentation, billing, reimbursement, payer requirements, audit methodology, operational workflows, and issue resolution.
Presents findings and recommendations to providers, administrative leaders, Coding leadership, and other stakeholders as appropriate.
Maintains complete, accurate, timely, objective, and defensible documentation supporting each review and its final disposition.
Maintains current knowledge of coding guidance, payer policies, reimbursement requirements, regulatory updates, documentation standards, and industry changes.
Maintains the confidentiality and security of patient, provider, employee, and business information.
Meets established quality, productivity, documentation, and turnaround-time expectations.
Assists with special projects and other coding, audit, reimbursement, system, workflow, or operational reviews as assigned.
Qualifications
MINIMUM QUALIFICATIONS
High school diploma or equivalent required. A four-year degree in Health Information Management, Healthcare Administration, Business, Finance, Nursing, or a related field is preferred. An equivalent combination of relevant education and experience may be considered.
Minimum of seven years of relevant experience in professional fee coding, coding audit, billing compliance, reimbursement, healthcare operations, or related revenue cycle functions required.
Minimum of three years of professional fee coding audit or complex coding review experience required. Experience must include independently reviewing medical records, determining findings, researching coding or payer guidance, documenting conclusions, and communicating findings to leadership or other stakeholders.
Demonstrated experience conducting investigations, performing root-cause analysis, validating findings, preparing written reports, coordinating with cross-functional stakeholders, and tracking issues through resolution required.
Experience reviewing multiple professional fee specialties is required. Experience in medical oncology, infusion, surgery, radiation oncology, evaluation and management services, and other oncology-related specialties is preferred.
Strong knowledge of CPT, HCPCS, ICD-10-CM, Evaluation and Management services, modifiers, medical necessity, provider documentation requirements, payer billing requirements, CMS guidance, NCCI edits, LCDs, NCDs, and professional fee reimbursement required.
Experience with coding and billing systems, electronic medical records, practice management systems, claim information, data analysis, and operational workflows required.
Experience supporting government, regulatory, payer, risk-based, focused, validation, or other complex reviews preferred.
LICENSES AND CERTIFICATIONS
Current professional coding certification required. Accepted primary credentials include:
Certified Professional Coder (CPC)
Certified Coding Specialist-Physician-based (CCS-P)
Certified Outpatient Coder (COC)
Registered Health Information Administrator (RHIA)
Registered Health Information Technician (RHIT)
A current auditing credential is also required. Accepted auditing credentials include:
Certified Professional Medical Auditor (CPMA)
Certified Healthcare Auditor (CHA)
Equivalent nationally recognized healthcare coding audit credential, subject to organizational approval
Candidates holding CPC, CCS-P, or COC must also possess an active auditing credential. A general inpatient-focused CCS credential alone does not satisfy the professional fee coding credential requirement.
Credential combinations that demonstrate both professional fee coding expertise and formal auditing competency are preferred. Examples include CPC and CPMA, CCS-P and CPMA, COC and CPMA, or RHIA/RHIT with a professional fee coding credential and CPMA.
All required credentials must be active and in good standing at the time of hire. The employee must maintain required credentials and continuing education requirements throughout employment.
Oncology, surgical, Evaluation and Management, compliance, clinical documentation, or specialty-specific credentials are preferred but do not replace the required professional coding and auditing credentials.
SPECIALIZED KNOWLEDGE AND SKILLS
The candidate must demonstrate the ability to
Evaluate an issue from coding, documentation, billing, reimbursement, system, workflow, operational, quality, and compliance-risk perspectives.
Approach reviews objectively without assuming the originally reported concern is the actual root cause.
Conduct an investigation and validate evidence before reaching or reporting a conclusion.
Distinguish between an isolated error, recurring trend, process weakness, system issue, knowledge gap, and broader organizational risk.
Determine the appropriate scope of review and identify potentially affected populations.
Interpret professional coding guidelines, payer policies, reimbursement requirements, medical record documentation, system data, and operational processes.
Identify when additional stakeholders or subject-matter experts must be involved.
Present findings objectively and support conclusions with medical record evidence, data, authoritative guidance, system evidence, and workflow validation.
Manage multiple complex reviews independently and meet established deadlines.
Coordinate cross-functional activities without direct supervisory authority.
Track corrective actions, maintain accountability, validate effectiveness, and close reviews appropriately.
Communicate complex findings clearly to technical and nontechnical audiences.
Prepare concise reports that identify the concern, work performed, evidence reviewed, findings, root cause, impact, recommendations, assigned actions, and closure status.
Exercise sound judgment, maintain objectivity, protect confidentiality, and escalate concerns appropriately.
Strong analytical, investigative, organizational, critical-thinking, written communication, verbal communication, follow-up, and problem-solving skills required.
Strong attention to detail required.
Ability to work independently and proactively with a sense of urgency and tact required.
Ability to manage competing priorities and adjust work based on organizational needs, risk, and business drivers required.
Proficiency with Microsoft Outlook, Word, Excel, and PowerPoint required. Experience with Power BI, Microsoft Lists, Access, audit software, electronic health records, practice management systems, claims systems, or other workflow and reporting tools preferred.
PHYSICAL DEMANDS
The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
While performing the duties of this job, the employee is required to be available during regularly scheduled business hours and is regularly required to sit or stand and talk or hear. The employee is frequently required to use hands to finger, handle, or feel and is occasionally required to reach with hands and arms.
The employee must frequently lift and/or move up to 10 pounds and occasionally lift and/or move up to 10 pounds. Specific vision abilities required by this job include close vision and the ability to adjust focus.
WORK ENVIRONMENT
The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
Work is performed in an office or remote environment and requires significant interaction with Coding Operations, Audit Operations, Education, Operations, Revenue Cycle, Information Technology, Compliance, reimbursement, clinical leadership, providers, and other corporate and network staff.
Work involves virtual and in-person interaction with coworkers, management, providers, business partners, and other stakeholders. Work may require minimal travel by automobile to other US Oncology locations.
Periodic flexibility in work hours may be required based on review deadlines, organizational priorities, or urgent matters.
ESSENTIAL DUTIES AND RESPONSIBILITIES
Performs complex reviews and investigations involving coding, documentation, billing, reimbursement, systems, workflows, operational processes, and related quality concerns.
Receives and evaluates review requests originating within Coding Operations or from organizational stakeholders requiring coding and operational expertise.
Establishes the appropriate scope and review methodology based on the reported concern, potential risk, available information, and affected services or processes.
Reviews medical records, provider documentation, coding, charges, claims, billing activity, system configuration, operational workflows, policies, procedures, and supporting data to determine the facts and circumstances related to each concern.
Evaluates concerns from all applicable perspectives and does not limit the investigation to the initially reported issue or assumed cause.
Determines whether the identified issue is related to coding, documentation, billing, reimbursement, payer requirements, system configuration, workflow, process design, training, staff activity, provider activity, or a combination of factors.
Conducts focused audits, medical record reviews, claim reviews, data validation, coding validation, and other investigative activities necessary to confirm the concern and determine its scope.
Researches applicable CPT, HCPCS, ICD-10-CM, CMS, Medicare Administrative Contractor, National Correct Coding Initiative, payer, regulatory, and organizational guidance.
Distinguishes between the reported concern, validated finding, contributing factors, and root cause before communicating conclusions.
Identifies the population, time frame, specialties, providers, locations, claims, charges, or workflows potentially affected by the issue.
Assesses the potential coding, documentation, billing, reimbursement, operational, financial, and compliance impact of validated findings.
Documents the concern received, investigative steps completed, evidence reviewed, findings, root cause, scope, impact, and recommended actions.
Ensures conclusions and recommendations are supported by medical record documentation, data, authoritative guidance, system evidence, workflow validation, or other appropriate supporting information.
Prepares clear and concise reports of findings and recommendations for Coding leadership and other appropriate stakeholders.
Identifies patterns, trends, control weaknesses, system issues, documentation deficiencies, coding concerns, billing risks, workflow barriers, and recurring operational problems.
Determines when additional departments or subject-matter experts must be involved and coordinates their participation in the review.
Collaborates with Coding Operations, Audit Operations, Education, Operations, Revenue Cycle, Information Technology, Compliance, reimbursement, clinical leadership, providers, and other stakeholders to validate findings and determine appropriate next steps.
Facilitates communication among involved stakeholders to clarify responsibilities, address dependencies, and prevent gaps in issue resolution.
Develops or recommends corrective actions based on the validated root cause, identified risk, and affected process.
Documents responsible owners, required actions, expected deliverables, and target completion dates based on leadership direction and the outcome of the review.
Tracks corrective actions, process changes, system corrections, coding updates, education, rebilling activities, workflow changes, and other re
