Senior Executive - Clinical Auditor

• 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