Senior Executive - Claims Audit

Job description

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.