Outpatient Coding Quality Auditor, Lead Associate- Remote (Any city, TX, US, 999

It takes great medical minds to create powerful solutions that solve some of healthcare’s most complex challenges. Join us and put your expertise to work in ways you never imagined possible. We know you’ve honed your career in a fast-moving medical environment. While Gainwell operates with a sense of urgency, you’ll have the opportunity to work more flexible hours. And working at Gainwell carries its rewards. You’ll have an incredible opportunity to grow your career in a company that values work-life balance, continuous learning, and career development.

Summary

The Lead Associate, Outpatient Coding Quality Auditor is responsible for conducting complex coding quality reviews of medical records and related documentation to validate coding accuracy, reimbursement compliance, and adherence to client-specific review methodologies. This role serves as a subject matter expert in outpatient coding, performing independent audits of coding and clinical staff work products, identifying coding opportunities, and providing regulatory and policy-based support for audit determinations.

The Lead Associate performs ongoing quality assurance activities to ensure consistency, accuracy, and compliance with federal, state, payer, and contract-specific requirements. This position requires extensive expertise in outpatient reimbursement methodologies, including Enhanced Ambulatory Patient Groups (EAPG), Ambulatory Payment Classifications (APC), and Ambulatory Surgery Center (ASC) payment systems, as well as a strong understanding of outpatient coding edits and payment integrity principles

Your role in our mission

- Conduct detailed reviews of medical records, claims, and supporting documentation to determine the accuracy and appropriateness of assigned ICD-10-CM, CPT, HCPCS Level II, and modifiers.

- Apply contract-specific review methodologies to identify coding discrepancies, billing errors, reimbursement inaccuracies, and compliance concerns.

- Evaluate documentation to ensure coding assignments are supported and compliant with applicable regulatory and payer requirements.

- Accurately document audit findings, rationale, and recommendations using proprietary audit and case management systems.

- Provide comprehensive coding and reimbursement determinations supported by clinical documentation, coding guidelines, payment methodologies, and regulatory requirements.

- Perform ongoing quality assurance audits of coding and clinical review staff to ensure accuracy, consistency, and adherence to established review methodologies.

- Interpret and apply official coding guidelines, CMS regulations, National Correct Coding Initiative (NCCI) edits, OPPS requirements, EAPG methodologies, APC payment policies, and ASC reimbursement guidelines.

- Assess auditor and reviewer performance against quality benchmarks and established productivity standards.

- Identify opportunities for process improvement and recommend corrective actions when quality concerns are identified.

- Participate in inter-rater reliability (IRR) activities and quality calibration sessions to promote consistency across review teams.

- Assist in developing quality monitoring processes, audit tools, and review protocols.

- Serve as a subject matter expert on outpatient coding, reimbursement methodologies, and payment integrity principles.

- Consistently achieves productivity and quality performance standards established by management.

What we're looking for

- One or more active professional credentials through AHIMA or AAPC: CPC, COC, CCS, RHIA, RHIT; required

- 3+ years experience in outpatient medical record coding required

- 3+ years of coding auditing, quality assurance, or coding validation experience required.

- Extensive experience reviewing outpatient facility claims and medical records.

- Demonstrated expertise in outpatient reimbursement methodologies, including: Enhanced Ambulatory Patient Groups (EAPG), Ambulatory Payment Classifications (APC), Ambulatory