Executive - Claims Audit

Job description

• Review and analyze medical records and claims data to ensure accuracy, completeness, and compliance with healthcare regulations and payer requirements.
• Verify that all necessary clinical documentation is included to support claim submissions and medical necessity.
• Identify and resolve inconsistencies, errors, or missing documentation in patient records or claims.
• Prioritize and manage workloads to ensure expedited and high-priority cases are processed within defined timelines.
• Collaborate with healthcare providers, coders, and billing staff to obtain or clarify necessary information.
• Ensure compliance with HIPAA, CMS, and other regulatory guidelines related to medical record handling and claims processing.
• Prepare accurate reports and summaries of claim findings, trends, and potential process improvements.
• Support internal audits and quality assurance initiatives by providing detailed documentation and analytical insights.
• Maintain a strong understanding of healthcare terminology, coding standards (ICD, CPT, HCPCS), and insurance claim procedures.

Responsibilities

• Complete the necessary training and meet the expectations outlined for the position.
• Follow all standard operating procedures (SOP) diligently.
• Complete audits promptly and ensure high quality.
• Strive to meet both quality and production targets.
• Adhere to project protocols and instructions.
• Report any issues or trends promptly.
• Maintain the logs (such as productivity, clarification, and others as applicable) updated.
• Seek clarification from the manager or team leader when needed.
• Promptly respond to all emails from the manager.
• Ensure compliance with all relevant regulations and policies.

Qualifications: Any Graduate/ Postgraduate

• Working Hours: 40 hours /week, Full Time Employee
• Work Model: Training from office for 2 - months and hybrid there after
• Telecommuter/Internet requirements, if applicable: High Speed internet connection and Power back up

Skills and abilities

• 3-5 years of Experience.
• Good communication, flexibility, reliability
• Knowledge in Microsoft outlook/excel/word/PPT.
• Strong Analytical skills with the ability to investigate and resolve issues
• Familiarity with HIPAA, Medicare, Medicaid and other payer specific regulations.