Senior 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.