Senior Executive - Clinical Auditor

Job description

- Job Description: Review and audit medical claims against patient medical records to ensure accuracy and completeness of documentation. - Identify discrepancies between clinical documentation and billed services, highlighting variances and potential billing errors. - Perform detailed clinical reviews to validate diagnosis, procedures, and level of care in accordance with industry standards. - Ensure compliance with CMS guidelines, payer policies, and regulatory requirements during claim review processes. - Conduct best practice audits to identify documentation gaps, coding inaccuracies, and revenue leakage opportunities. - Provide structured findings and audit reports with clear recommendations for corrective action and process improvement. - Collaborate with coding, billing, and provider teams to resolve audit findings and support accurate claim submissions. - Monitor trends in audit results and identify recurring issues requiring targeted education or intervention. - Support quality assurance initiatives by maintaining audit accuracy benchmarks and meeting productivity standards. - Participate in continuous improvement activities, including updates on CMS regulations, clinical guidelines, and payer policy changes. - Responsibilities: Familiarity with basic medical terminology and concepts used in care management. - Ability to effectively participate in a multi-disciplinary team including internal and external participants. - Should have a good understanding of US healthcare system and management. - Perform audit based on clinical knowledge while reviewing the medical record - Demonstrate learning skills during process training and in advancing career - Perform quality assurance reviews to assess comprehension of training efforts. - Ensure to process the audit with accountability - Ensure to view all documented system information as well as any additional records/data presented to support a determination or recommendation. - Condenses all clinical information into a clear and precise clinical picture while taking a final decision. - Pro-actively and consistently engage in enhancing process/work knowledge and delivery the work with high values. - Actively update process knowledge and follow the new change in process. - Be ready to analyze the errors and if required approach to quality team for further clarification. - Maintain a professional work environment. - Follow every aspect of SOP without fail. - Complete received Audits with Quality. - Achieve expected Quality and production target. - Follow project-related protocols and instructions. - Update all the logs like productivity, Clarification log, and any other logs applicable daily. - Complete alignment with Manager /TL in terms of program delivery. - Responding to all emails promptly without fail. - Ensure compliance of the entire team. - **Qualifications: Qualifications:** - Bachelor’s degree in nursing - Active State Nursing certification is Mandatory - Minimum 3 years of clinical/hospital experience is mandatory - **Experience:** - Minimum 3 years of clinical experience. - Auditing experience (Optional) - **Communication:** - Strong written (documentation) and oral communication skills - **Working Hours:** - 40 hours per week as Full-time employee - Shift time: 08:00 AM TO 05:00 PM IST (It might be changed based on project requirements) - Weekends: Off - **Telecommuter/Internet requirements, if applicable:** - High Speed internet connection at home, must be broadband - Must understand and adhere with telecommuter policy