HIM Cert Coder​/Quality Review Analyst OP

Overview

This position is responsible for timely and accurate quality review of both internal and vendor coding team members to assure compliance with coding guidelines and standards in addition to their foundation coding responsibilities. The position performs quality checks on coding and provides feedback to coders to assure the timely and accurate coding of medical charts for billing. This position also reviews and responds to coding-based denials for inpatient, hospital outpatient, and professional fee claims and advises leadership on trends related to denials.

In collaboration with HIM coding management, the coder/quality review analyst will assist with selection of coders and encounters to be reviewed, as well as education to be presented to the coder based on review outcomes. The coder/quality review analyst will also bring forward any issues related to documentation or systems as they are discovered during the review process. This position participates in the onboarding process of new coders, which may require intensive audits and reviews until the coder is fully trained and released.

• Certified Professional Coder (CPC) – American Academy of Professional Coders (AAPC)
• Certified Coding Associate (CCA) – American Health Information Management Association (AHIMA)
• Certified Coding Specialist (CCS) – American Health Information Management Association (AHIMA)
• Registered Health Information Administrator (RHIA) – American Health Information Management Association (AHIMA)
• Registered Health Information Technician (RHIT) – American Health Information Management Association (AHIMA)
• Certified Professional Coder – Payer (CPC‑P) – American Academy of Professional Coders (AAPC)
• Certified Professional Coder – Hospital (CPCH) – American Academy of Professional Coders (AAPC)

Education:

Work Experience:

Coding

• Perform accurate and timely quality reviews of internal and vendor coding team members using appropriate code sets and coding guidelines.
• Develop and perform timely coding education to internal and vendor coding team members on coding systems, coding standards, protocols and Carle coding workflow as required based on quality review outcomes.
• Perform as a production coder when needed in a manner aligned with current coding productivity and quality standards.
• Share results of quality reviews with HIM Leadership, providing recommendations for education and training.
• Work with HIM leadership to determine frequency and scope of coding quality reviews for specific coders and vendors.
• Compile and track statistics related to the review function, completed quality reviews, and follow‑up from those reviews.
• Identify coder training needs, system issues, and/or documentation issues, and report them timely to HIM leadership.
• Review and respond to coding denials and coding questions as requested or assigned, performing clinical validation of appeal letters as needed.
• Assist in editing appeal letters, ensuring clinical documentation support and regulatory guidelines are considered.
• Participate in system and new application testing as needed.
• Review and resolve coding‑based denials using EPIC WQs or other software.
• Provide denial trending data to leadership as requested.
• Work with Manager to analyze denied claims and identify trends for education.
• Serve as subject‑matter expert (SME) for coding denials, providing guidance and education to coding staff, physicians, and other hospital departments.
• Provide regular reports to management on denial trends, appeal outcomes, and overall performance metrics.
• Identify work types to be reviewed based on the coding scope and new coder onboarding needs of the HIM department.
• Develop and perform HIM coding team member group education on coding topics identified during quality reviews and denial reviews.
• Assist the HIM coding management in assuring all coding performed by HIM or HIM vendors meets department standards.

Discover the job, the career, the purpose you were meant for. The supportive and inclusive team where you can thrive. The place where growth meets balance – and opportunities meet flexibility. Find it all at Carle Health.

Based in Urbana, IL, Carle Health…