Quality Validation Specialist

The Rawlings Group; United States; Remote; USD 94,500 - 115,500; Full time

Benefits offered by this job

PTO and holidays

Health, vision and dental coverage

401(k) with company match

Tuition reimbursement

Life insurance and disability benefits

Remote or hybrid work options

Job summary

Machinify is seeking a Quality Validation Specialist to review outpatient coding validation audits, ensure accuracy, and support continuous quality improvement. You will evaluate auditor performance, provide coaching, and maintain QA tools and documentation.

The role emphasizes adherence to Official Coding Guidelines, CMS rules, and AHIMA/AAPC standards. You will work with leadership to refine audit methodologies, standardize scoring, and monitor QA metrics while staying current on Medicare

Qualifications

• Requires AHIMA/AAPC certification or active credentials
• Minimum 5 years of hospital outpatient coding experience in OPPS/Audit
• Strong knowledge of CPT, HCPCS Level II, ICD-10-CM and NCCI edits
• Experience with encoder/auditing tools like Optum, TrueBridge, 3M

Responsibilities

• Perform secondary reviews of outpatient coding validation audits for accuracy and compliance
• Evaluate auditor performance against quality benchmarks and provide actionable feedback
• Develop and maintain QA tools, scorecards, and documentation standards
• Collaborate with leadership to improve audit methodologies and coding guidance
• Monitor QA metrics and report trends to leadership
• Validate CPT, HCPCS Level II, and ICD-10-CM coding accuracy with appropriate references

Skills

Coding knowledge

Analytical thinking

Communication skills

Independent worker

Education

Health Information Management degree

Tools

Optum

3M

TrueBridge

Job description

Machinify is a leading healthcare intelligence company with expertise across the payment continuum, delivering unmatched value, transparency, and efficiency to health plan clients across the country. Deployed by over 85 health plans, including many of the top 20, and representing more than 270 million lives, Machinify brings together a fully configurable and content‑rich, AI‑powered platform along with best‑in‑class expertise. We're constantly reimagining what's possible in our industry, creating disruptively simple, powerfully clear ways to maximize financial outcomes and drive down healthcare costs.

About the Opportunity

The Quality Validation Specialist reviews completed outpatient coding validation audits to ensure accuracy, consistency, compliance, and adherence to client, regulatory, and organizational standards. This role evaluates audit quality related to APCs, EAPGs, CPT, HCPCS Level II, and ICD-10‑CM coding while supporting continuous improvement initiatives across the validation process. The Quality Validation Specialist identifies trends, provides actionable feedback and education, monitors auditor performance, and promotes standardized application of coding guidelines and reimbursement methodologies. This position partners closely with leadership to enhance audit quality, maintain compliance, and support operational excellence.

What you'll do

• Performs secondary reviews of completed outpatient coding validation audits to verify coding accuracy, supporting rationale, and compliance with official coding guidelines, payer policies, reimbursement methodologies, and internal audit standards.
• Evaluates auditor performance against established quality and accuracy benchmarks, identifying trends, educational opportunities, and areas requiring corrective action.
• Provides detailed, constructive feedback and coaching to auditors to promote consistency, accuracy, and appropriate interpretation and application of coding and billing guidelines.
• Develops, maintains, and enhances quality assurance tools, scorecards, audit tracking mechanisms, and documentation standards to support objective and consistent review processes.
• Collaborates with leadership and operational teams to improve audit methodologies, clarify coding guidance, standardize processes, and support continuous quality improvement initiatives.
• Validates accurate assignment and review of CPT, HCPCS Level II, and ICD‑10‑CM codes, including appropriate use of modifiers and supporting references such as Official Coding Guidelines, CMS regulations, AMA guidance, LCDs, and NCDs.
• Develops and maintains QA tools, scorecards, and documentation standards to support objective review processes.
• Monitors and reports QA metrics, audit findings, quality trends, and corrective action plans to leadership for performance oversight and operational improvement.
• Maintains current knowledge of outpatient reimbursement methodologies, regulatory updates, coding changes, and industry standards related to Medicare OPPS, APCs, and EAPGs.
• Ensures adherence to ethical coding and auditing standards established by AHIMA, AAPC, CMS, and organizational compliance policies.
• Performs secondary reviews across multiple audit and coding platforms while maintaining established productivity and quality expectations.
• Assists with development and delivery of training materials and educational resources related to identified trends, coding updates, policy changes, and performance improvement opportunities.
• Participates in calibration sessions and quality consistency initiatives to ensure standardized audit interpretation and scoring methodologies.
• Performs other duties as assigned.

What experience you bring (Role Requirements)

Required Qualifications

• Associate's or Bachelor's degree in Health Information Management, Healthcare Administration, or a related field preferred.
• Current certification through AHIMA and/or AAPC required, including one or more of the following:
• RHIA (Registered Health Information Administrator)
• RHIA (Registered Health Information Administrator)
• CCS (Certified Coding Specialist)
• CPC (Certified Professional Coder)
• Minimum of 5 years of hospital outpatient coding experience within OPPS reimbursement methodologies and/or at least 5 years of outpatient/APC validation auditing experience.
• Extensive knowledge of CPT, HCPCS Level II, ICD‑10‑CM, NCCI edits, and appropriate modifier usage.
• Strong understanding of Medicare Outpatient Prospective Payment System (OPPS), Ambulatory Payment Classifications (APCs), and outpatient reimbursement methodologies.
• Proficiency interpreting and applying Medicare LCD and NCD guidelines.
• Experience using industry‑standard encoder and auditing tools such as Optum, TrueBridge, and/or 3M.
• Demonstrated ability to review and validate a broad range of outpatient facility services and claim types.
• Strong analytical, critical thinking, organizational, and problem‑solving skills.
• Excellent verbal and written communication skills with the ability to provide clear, professional feedback and education.
• Ability to work independently and collaboratively in a fast‑paced production and quality‑driven environment.

Preferred Qualifications

• 5-7 years of experience performing pre‑pay, post‑pay, and/or post‑adjudication outpatient validation reviews related to OPPS/APC reimbursement.
• Advanced experience auditing or coding complex outpatient facility claims, including but not limited to:
• Interventional Radiology
• Radiation Oncology
• Behavioral Health
• Ambulatory Surgery
• Cardiac Catheterization
• Implants
• Injections and Infusions
• Emergency Department - including ED E&M Leveling
• Observation Services and carve‑out reimbursement scenarios
• Experience coding, auditing, or validating Enhanced Ambulatory Patient Grouping (EAPG) claims.
• Prior quality assurance, auditor mentoring, training, or team lead experience preferred.

What Success Looks Like

After 3 months

You will have a strong understanding of the role.

You begin building relationships and collaborating with peers.

You develop effective time and priorities management.

You receive initial feedback about your performance and are using it to improve.

You've gained confidence in your abilities and are starting to feel more comfortable in your role.

After 1 year

You have mastered the tasks and responsibilities of the position, executing them with confidence and efficiency.

You have established a strong network of internal relationships and are recognized as a key collaborator.

You've been entrusted with greater responsibility indicating the company's confidence in your abilities.

You see opportunities for career progression and personal development.

Pay range

This is an exempt position starting at $105,000 with bonus opportunity. The salary range is for Base Salary. Compensation will be determined based on several factors including, but not limited to, skill set, years of experience, and the employee's geographic location.

What's in it for you

• PTO, Paid Holidays, and Volunteer Days
• Eligibility for health, vision and dental coverage, 401(k) plan participation with company match, and flexible spending accounts
• Tuition Reimbursement
• Eligibility for company‑paid benefits including life insurance, short‑term disability, and parental leave.
• Remote and hybrid work options

Equal Employment Opportunity at Machinify

We are committed to equal employment opportunity regardless of race, color, ancestry, religion, sex, national origin, sexual orientation, age, citizenship, marital status, disability, gender, gender identity or expression, or veteran status. We are proud to be an equal opportunity workplace. Machinify is an employment at will employer. We participate in E-Verify as required by applicable law. In accordance with applicable state laws, we do not inquire about salary history during the recruitment process. If you require a reasonable accommodation to complete any part of the application or recruitment process, please let our recruiters know. See our Candidate Privacy Notice at: https://www.machinify.com/candidate-privacy-notice/.