Quality Assurance Specialist III - Operations

Ampcus Inc. is a certified global provider of a broad range of Technology and Business consulting services. We are in search of a highly motivated candidate to join our talented Team.

Job Title: Quality Assurance Specialist III - Operations

Work Site Location: Reston, VA ( Hybrid )

Job Summary:

The Special Investigations Unit (SIU) is currently managing a claim volume exceeding 5,000, which has significantly impacted our operational capacity. Due to existing bandwidth limitations, approval was granted to secure temporary support to help reduce the backlog and maintain timely investigative processes.

This additional resourcing is essential to ensure continued compliance, mitigate risk, and uphold the integrity of our claims review process.

Key Responsibilities:

• Responsibilities will include reviewing provider claims with medical records for SIU prepayment team. The role is to ensure properly coded claims in accordance with AMA, industry standards, and identification of FWA indicators.

• Acts as an internal expert to ensure that as value-based reimbursement and medical policy models are developed and implemented. Provides advanced knowledge to support effective partnership with provider entities and guidance on the appropriate quality measure capture and proper use of CPT and ICD 10 codes in claims submissions.
• Utilizes extensive coding knowledge, combined with medical policy, credentialing, and contracting rules knowledge to help build the effective guides and resources for providers on the expected methodologies for billing and code submissions to maximize quality and STARs outcomes while not compromising payment integrity.
• Consults on proper coding rules in value-based contracts to ensure appropriate quality measure capture and proper use of CPT and ICD10 codes. Provides input on various consequences for different financial and incentive models. Supports to use of alternatives and solutions to maximize quality payments and risk adjustment. Translates from claim language to services in an episode or capitated payment to articulate inclusions and exclusions in models.
• Serves as a technical resource / coding subject matter expert for contract pricing related issues. Conducts business and operational analyses to assure payments are in compliance with contract; identifies areas for improvement and clarification for better operational efficiency. Provides problem solving expertise on systems issues if a code is not accepted. Troubleshoots, make recommendations and answer questions on more complex coding and billing issues whether systemic or one-off.
• Supports and contributes to the development and refinement of effective guides and resources for providers on the expected methodologies for billing and code submissions to maximize quality and STARs outcomes while not compromising payment integrity. May interface directly with provider groups during proactive training events or just in time on complex claims matters. Consults with various teams, including the Practice Transformation Consultants, Medical Policy Analysts and Provider Networks colleagues to interpret coding and documentation language and respond to inquiries from providers.

• Bachelor's degree in related discipline
• Experience in medical auditing
• Experience in training/education/presenting to large groups
• Experience in revenue cycle management and value-based reimbursement/contracting models and methodologies

• Knowledge of billing practices for hospitals, physicians and/or ancillary providers as well as knowledge about contracting and claims processing Proficient
• Knowledge and understanding of medical terminology to address codes and procedures. Advanced
• Excellent communication skills both written and verbal. Proficient
• Detail oriented with an ability to manage multiple projects simultaneously Proficient
• Demonstrated ability to effectively analyze and present data Proficient
• Experience in using Microsoft Office (Excel, Word, Power Point, etc.) and demonstrated ability to learn/adapt to computer-based tracking and data collection tools Proficient

• High School Diploma

• CPC, CPMA, COC through AAPC.

• 3 years experience in risk adjustment coding, ambulatory coding and/or CRC coding experience in managed care; state or federal health care programs; or health insurance industry experience

Ampcus is an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, age, protected veterans or individuals with disabilities.