Payment Integrity Complex & Clinical Audit (Quality Analyst Medical Coding Certified)
Are you a clinically trained professional with a strong eye for detail and a passion for audit quality
Join our Payment Integrity team and play a critical role in ensuring accurate DRG validation and clinical audit outcomes across complex healthcare transactions.
About the Company
We support enterprise-wide healthcare payment integrity initiatives by delivering high-quality clinical and coding audits. Our teams partner closely with internal and external stakeholders to ensure accuracy, compliance, and continuous improvement in healthcare reimbursement and documentation practices.
About the Role
The Quality Analyst (Medical Coding Certified) will support leadership and DRG Validation Auditor associates by evaluating audit quality, identifying trends, and driving corrective actions. This role involves conducting routine to complex audits across systems and lines of business, with a strong focus on clinical accuracy, documentation standards, and audit consistency.
Key Responsibilities
- Evaluate the quality and accuracy of audit transactions and communications with providers, groups, and policyholders
- Identify, document, and report errors or quality issues to ensure timely resolution
- Track and trend audit results; provide actionable feedback to management
- Conduct calibration sessions to ensure alignment with QA guidelines
- Identify systemic quality issues and perform root cause analysis (RCA)
- Recommend, implement, and monitor corrective and preventive actions
- Generate monthly audit reports and support ad hoc reporting requests
- Support internal and external stakeholders with audit findings and insights
- Contribute to process improvement and efficiency initiatives
Must-Have Qualifications
- At least 3 years of Quality Assurance (QA) experience
- Current and active Philippine Registered Nurse (RN) license
- Minimum of 2 years hospital experience and/or several years of inpatient hospital coding experience
- Working knowledge of the healthcare industry and medical terminology
- Proven understanding of healthcare processing principles, techniques, and guidelines
- Ability to conduct routine to complex audits across systems and lines of business
Good-to-Have Qualifications
- Experience with DRG coding and/or clinical validation audits
- Background in Clinical Documentation Improvement (CDI)
- Broad knowledge of:
- Clinical documentation improvement guidelines
- Medical claims billing and payment systems
- Provider billing guidelines and payer reimbursement policies
Preferred Certifications
- Certified Clinical Documentation Specialist (CCDS)
- Certified Documentation Improvement Practitioner (CDIP)
- Certified Professional Coder (CPC)
- Inpatient coding credentials such as CCS or CIC
Why Join Us
- Be part of a specialized Payment Integrity and Clinical Audit function
- Work on complex, high-impact healthcare audits
- Collaborate with experienced clinical and coding professionals
- Influence quality standards and continuous improvement initiatives
How to Apply
Apply directly through LinkedIn by submitting your updated resume. Qualified candidates will be contacted for the next steps.
