Quality Validation Specialist

Machinify; United States; Hybrid; USD 94,500 - 115,500; Full time

Benefits offered by this job

PTO and paid holidays

Health, vision, and dental coverage

401(k) plan with company match

Tuition reimbursement

Remote and hybrid work options

Job summary

Machinify is seeking a Quality Validation Specialist to review outpatient coding validation audits for accuracy and compliance. This role is crucial in ensuring adherence to official coding guidelines and will involve evaluating auditor performance and providing constructive feedback.

Candidates should have a degree in Health Information Management and current certification. The position offers a starting salary of $105,000 plus benefits, with opportunities for remote and hybrid work.

Qualifications

• Minimum of 5 years of hospital outpatient coding experience.
• Demonstrated ability to review and validate a broad range of outpatient facility services.
• Strong understanding of Medicare Outpatient Prospective Payment System (OPPS).

Responsibilities

• Review outpatient coding validation audits for accuracy and compliance.
• Evaluate auditor performance and identify trends for improvement.
• Provide feedback and coaching for coding accuracy.

Skills

CPT coding

ICD-10-CM coding

HCPCS Level II coding

Analytical skills

Communication skills

Education

Associate’s or Bachelor’s degree in Health Information Management

Certification through AHIMA or AAPC

Tools

Optum

TrueBridge

3M

Job description

Machinify is a leading healthcare intelligence company that harnesses AI to deliver unmatched value, transparency, and efficiency to health plan clients across the country, supporting more than 270 million lives through a fully configurable, content‑rich platform and top‑tier expertise.

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 specialist identifies trends, provides actionable feedback and education, monitors auditor performance, and promotes standardized application of coding guidelines and reimbursement methodologies.

What You’ll Do

• Perform 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.
• Evaluate auditor performance against established quality and accuracy benchmarks, identifying trends, educational opportunities, and areas requiring corrective action.
• Provide detailed, constructive feedback and coaching to auditors to promote consistency, accuracy, and appropriate interpretation and application of coding and billing guidelines.
• Develop, maintain, and enhance quality assurance tools, scorecards, audit tracking mechanisms, and documentation standards to support objective and consistent review processes.
• Collaborate with leadership and operational teams to improve audit methodologies, clarify coding guidance, standardize processes, and support continuous quality improvement initiatives.
• Validate 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.
• Monitor and report QA metrics, audit findings, quality trends, and corrective action plans to leadership for performance oversight and operational improvement.
• Maintain current knowledge of outpatient reimbursement methodologies, regulatory updates, coding changes, and industry standards related to Medicare OPPS, APCs, and EAPGs.
• Ensure adherence to ethical coding and auditing standards established by AHIMA, AAPC, CMS, and organizational compliance policies.
• Perform secondary reviews across multiple audit and coding platforms while meeting established productivity and quality expectations.
• Assist with development and delivery of training materials and educational resources related to identified trends, coding updates, policy changes, and performance improvement opportunities.
• Participate in calibration sessions and quality consistency initiatives to ensure standardized audit interpretation and scoring methodologies.
• Perform other duties as assigned.

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, including RHIA, CCS, or CPC.
• 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‑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 interventional radiology, radiation oncology, behavioral health, ambulatory surgery, implants, injections and infusions, observation services, and carve‑out reimbursement scenarios.
• Experience coding, auditing, or validating Enhanced Ambulatory Patient Groupings (EAPGs).
• Prior quality assurance, auditor mentoring, training, or team‑lead experience.

Pay Range

This is an exempt position with a base salary starting at $105,000, plus bonus opportunity. Compensation will be adjusted based on skill set, experience, and geographic location.

Benefits

• PTO, paid holidays, and volunteer days
• Eligibility for health, vision, and dental coverage, 401(k) plan 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

Machinify is 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. Machinify is an employment‑at‑will employer and participates 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.