Quality Validation Specialist

About the role

Machinify is a leading healthcare intelligence company that delivers unmatched value, transparency, and efficiency to health plan clients. The Quality Validation Specialist role involves reviewing outpatient coding validation audits to ensure accuracy, compliance, and adherence to standards.

Responsibilities

• 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.
• 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.

Requirements

• 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, RHIT, CCS, 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 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.

Benefits

• PTO, Paid Holidays, and Volunteer Days
• Health, Vision, and Dental coverage
• 401(k) plan participation with company match
• Flexible Spending Accounts
• Tuition Reimbursement
• Life Insurance, Short-Term Disability, and Parental Leave
• Remote and Hybrid Work Options