Medical Billing Quality Assurance (QA) Officer

Job Summary:

The Medical Billing Quality Assurance Officer is responsible for executing internal audit protocols across the medical billing and coding lifecycles. This professional monitors charge capture, claim form fields, modifier placements, and Accounts Receivable (AR) follow-up processes to ensure strict alignment with CMS guidelines, HIPAA regulations, and payer-specific policies. By analyzing error trends and delivering targeted coaching, the QA Officer actively minimizes claim denials, lowers Days Sales Outstanding (DSO), and shields the healthcare organization from structural compliance risks.

Core Duties and Responsibilities:

• Routine Claims & Process Audits: Conduct random and targeted internal audits on submitted claims, payment postings, and patient statements across multiple source systems (EHR/Billing software) to measure accuracy against established Service Level Agreements (SLAs).
• Code Verification & Compliance Tracking: Validate that applied ICD-10-CM, CPT, and HCPCS codes accurately reflect the clinical documentation. Screen pre-submission claims for upcoding, undercoding, unbundling errors, and missing modifiers using NCCI (National Correct Coding Initiative) edits.
• Denial & Rejection Root-Cause Analysis: Review clearinghouse rejections and insurance denials to pinpoint structural workflows or system glitches. Trend the data by team or individual to implement long-term corrective action plans.
• Staff Feedback & Coaching: Package audit metrics into clear, actionable reporting dashboards. Conduct standard calibration sessions and retraining with medical billers, coders, and AR specialists to reduce performance deficiencies.
• Payer Guideline Management: Maintain an updated knowledge base of evolving state/federal regulations (Medicare, Medicaid) and commercial insurance policies. Ensure internal Standard Operating Procedures (SOPs) are updated to match quarterly code changes.
• AR and Ledger Integrity Reviews: Meticulously review accounts receivable follow-up records to confirm that staff are properly appealing denials, managing outstanding balances ethically, and applying payment plans appropriately.

Required Skills and Qualifications:

• In-Depth RCM Expertise: Comprehensive understanding of the end-to-end insurance claim lifecycle, commercial/government clearinghouse procedures, and medical terminology.
• Advanced Coding Literacy: High proficiency interpreting guidelines within ICD-10-CM, CPT, and HCPCS codebooks, alongside a firm grasp of payer-specific bundling rules.
• Data-Driven Analysis: Strong analytical mindset with the ability to define distinct billing problems, extract performance data, establish root causes, and draw objective conclusions.
• Communication & Collaboration: Diplomatic, plain-language interpersonal communication style. Able to deliver constructive performance evaluations to staff and translate technical compliance data clearly to leadership.
• Software Proficiency: Hands-on experience navigating enterprise Electronic Health Record (EHR) databases and industry-standard billing platforms (e.g., Epic, Cerner, eClinicalWorks) alongside advanced proficiency in MS Excel for auditing logs.

Education and Experience Requirements:

• Education: Associate’s or Bachelor’s degree in Healthcare Administration, Finance, Business, or a closely related field (or equivalent verified experience).
• Experience: Minimum of 2 years of direct experience in medical billing, coding, or healthcare data auditing. Proven experience in an auditing or supervisory capacity is heavily preferred.

Pay: Rs100,000.00 - Rs150,000.00 per month

Work Location: Remote