QA Auditor- Medical Necessity
PRGX Global - Remote

This job posting is no longer available on PRGX Global. Find similar jobs: QA Auditor jobs - PRGX Global jobs


The purpose of this Med Necessity QA position is to provide support to quality/training within the Healthcare Audit Service Group. The Med Necessity QA position will provide daily support to quality assurance of initial auditor findings of claims, review and provide feedback from quality reviews, monitor trends, reporting of findings, training as needed, report financial impacts of QA missed opportunities, monitor QA of new auditors, monthly and quarterly quality assurance reviews, and other duties on as needed basis.

The Med Necessity QA in addition to the above responsibilities may perform various duties as assigned by Healthcare audit management, and on occasion and as necessary the Med Necessity QA may also perform DRG coding/ validation initial audits to assist in meeting PRGX production goals, may assits in the discussion process as well.


Quality Assurance

Perform QA reviews as scheduled; document results; provide metrics to management; provide feedback in report format

New hire and Quarterly QA for assigned team members

Quarterly QA for overall Healthcare Audit

% of no findings

% of findings to ensure accuracy

Review of RVC quarterly samples for each prime

Review special study request

Review QA Samples from primes

Review MAC Appeal overturns

Assist with provider discussion

May assist in ALJ preparation of cases as needed

Participation in meetings with internal/external clients as needed

Education & Training

Provide recommendations for overall team education and training as a result of QA findings

Assist/provide Director and Chief Medical Director in preparing education sessions

Conduct any education sessions across entire audit area as requested

Creating of training materials, (DTOPS, bulletins )


Reports for trending/training

Financial impact reports

QA result repots/recommendation

Wave reports (what are we seeing that could impact either positive/negative with wave selection

Team Performance Monitoring, Coaching & Development

Monitor individual and team performance metrics on a daily basis; alert management to any notable issues.

Mentor / coach team members to enable achievement of productivity and quality goals

Provide input into performance evaluations

Contributes to the success of the organization by helping others accomplish job results; learning new skills needed by the team; finding new ways to help the team.

work experience AND EDUCATION requirements

Credentials Required: Registered Nurse

Credentials preferred: : RHIT, RHIA, CPC, CPC-H, or Certified Coding Specialist ( CCS ).

Experience Required: must have at least 5 years of inpatient coding and/or auditing experience with basic knowledge of hospital claims. Must possess an understanding and working knowledge of a coding and grouper system, preferably the TruCode Coding and Grouper System, as well as the application of Coding Clinic Guidelines. Must have an understanding of Medicare reimbursement rules and regulations as they relate to inpatient hospitals and / or other third party payer specific guidelines such as Medicaid or Private Insurance as applicable. Prior supervisory experience is desired.


The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. While performing the duties of this job, the employee is occasionally required to remain stationary; move; lift and/or move up to 15 pounds. The employee must regularly sit; use hands to finger, handle, or feel; reach with hands and arms; communicate. Specific vision abilities required by this job include close vision.

The Company does not discriminate against employees or applicants for employment based upon race, color, national origin, genetic information, religious beliefs, gender, age, marital status, disability, U.S. veteran status, or any other protected classifications, activities, or conditions as required by federal, state and local laws.

About this company
5 reviews