About this role
• 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.
• 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: • 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