Outpatient- Quality Manager

The role directly manages a team of outpatient quality analysts responsible for reviewing auditor-completed outpatient facility coding audits, ATA audits, validating audit accuracy, and ensuring accurate coding, billing, reimbursement, and documentation outcomes. The ideal candidate demonstrates strong leadership and analytical skills, along with expertise in ICD-10-CM, CPT, HCPCS, modifiers, OPPS/APC reimbursement, NCCI edits, LCD/NCD requirements, payer policies, audit tools, and outpatient quality review standards.

Salary Range: $100,000 – $120,000, based on experience, skills, and qualifications.
Location: 100% Remote, U.S.-based.

Travel: Limited travel may be required for team meetings.
A brief outpatient coding/auditing assessment may be included as part of the interview process.
For more information on benefits and what we offer, please visit us at https://www.exlservice.com/us-careers-and-benefits.

For more information on benefits and what we offer, please visit us at https://www.exlservice.com/us-careers-and-benefits.

Responsibilities

• Actively drive the execution and ongoing improvement of outpatient coding quality review programs, including initial audits, appeals, targeted reviews, provider- or concept-specific reviews, and ATA audits.

• Manage day-to-day outpatient quality review operations, including workflow distribution, inventory, QA aging, productivity, timeliness, client SLAs, quality expectations, and internal standards.

• Provide direct supervision to outpatient quality analysts through coaching, feedback, performance management, one-on-ones, training, development planning, and ongoing upskilling.

• Analyze audit accuracy, productivity, QA inventory, defect trends, root cause analysis, auditor performance, documentation patterns, and quality performance metrics to take action that improves team performance and overall quality results.

• Perform ATA audits as part of the team’s outpatient quality review activities, ensuring audit determinations, documentation support, rationales, and quality outcomes are accurate, consistent, and aligned with client and program expectations.

• Ensure RCA categories are marked appropriately and that recurring trends result in timely follow-up, coaching, clarification, process correction, or escalation as needed.

• Lead regular calibration with outpatient quality analysts to promote consistent review decisions, aligned rationale documentation, appropriate RCA selection, and consistent application of coding and payer guidance.

• Partner with Operations, Training, Technology, clients, and global partners to drive consistency, resolve quality or operational issues, and support outpatient audit quality solutions.

• Support program implementations and operational initiatives by defining outpatient quality expectations, review criteria, sampling approaches, workflow needs, reporting requirements, and quality control processes.

• Identify responsible AI-in-the-workflow opportunities that improve audit quality, consistency, efficiency, trend identification, documentation support, and team productivity while maintaining appropriate human review, compliance, and data security expectations.

• Monitor CMS, payer, LCD/NCD, NCCI, OPPS/APC, CPT, HCPCS, modifier, and ICD-10-CM guideline updates to ensure quality reviews remain compliant and current.

• Conduct all job functions and responsibilities in accordance with all company Compliance, Information Security, and Regulatory policies, procedures, and programs.

Qualifications

Experience

• CCS, CPC, RHIT, RHIA, or other relevant coding credential required; CCS or CPC preferred.

• Minimum 5 years of outpatient facility coding, auditing, or quality review experience, with demonstrated understanding of ICD-10-CM, CPT, HCPCS, modifiers, OPPS, APC reimbursement, and outpatient payment methodologies.

• Prior leadership, supervisory, quality management, or team lead experience required.

• Experience applying Medicare Local Coverage Determinations (LCDs), National Coverage Determinations (NCDs), NCCI edits, payer policies, and medical necessity requirements.

• Experience with outpatient audit operations, quality assurance processes, root cause analysis, coaching, and performance improvement.

Skills & Competencies

• Strong outpatient coding expertise across complex facility services such as interventional radiology, ambulatory surgery, emergency department, observation, infusion/injection, wound care, and diagnostic services.

• Proficient in modifier application, CPT/HCPCS coding, ICD-10-CM coding, NCCI edits, MUEs, and appropriate Medicare and payer-specific guidelines.

• Ability to evaluate audit accuracy, determine whether findings and no-findings are supported, and validate clear rationale based on documentation and authoritative coding guidance.

• Ability to write professional quality notes citing Official Coding Guidelines, CPT/HCPCS guidance, Coding Clinic, AMA CPT Assistant, CMS guidance, LCD/NCD policies, and other recognized sources as appropriate.

• Strong leadership, coaching, and mentoring skills with the ability to develop outpatient quality analysts and support consistent audit decision-making.

• Excellent verbal and written communication skills, including the ability to explain complex coding and quality concepts clearly.

• Strong analytical, root cause analysis, decision-making, and problem-solving skills.

• Strong organizational skills, attention to detail, and ability to manage competing priorities, inventory, and deadlines.

• Ability to work independently and collaboratively with Operations, Training, Technology, clients, and global partners.

• Demonstrated flexibility, adaptability, accountability, and sound judgment in a fast-paced audit environment.

• Strong technical knowledge and ability to learn new audit tools, reporting platforms, and workflow systems quickly.

• Digital mindset with the ability to appropriately leverage approved AI-enabled tools and workflow technology to enhance quality monitoring, reporting, root cause analysis, calibration preparation, and operational efficiency.

• Proficiency with Excel, PowerPoint, Outlook, Word, and audit productivity or reporting tools.

• Strong interpersonal skills with the ability to promote accountability, collaboration, and consistent quality practices across the team.

What We Offer

• EXL Health offers an exciting, fast paced, and innovative environment, which brings together a group of sharp and entrepreneurial professionals who are eager to influence business decisions. From your very first day, you get an opportunity to work closely with highly experienced, world class Healthcare consultants
• You can expect to learn many aspects of businesses that our clients engage in. You will also learn effective teamwork and time-management skills—key aspects for personal and professional growth
• We provide guidance/coaching to every employee through our mentoring program wherein every junior-level employee is assigned a senior-level professional as an advisor
• The sky is the limit for our team members. The unique experiences gathered at EXL Health sets the stage for further growth and development in our company and beyond

The posted base salary range is the hiring base salary range for this role. Final offers are based on several factors, including: the candidate's skills and experience, internal pay equity, work location, market conditions for the role, and the specific scope and responsibilities of the position.