Job Description

The Quality Assurance Auditor is responsible for conducting detailed audits of all billing activities and accounts worked within the billing software system. This includes reviewing claim follow-up, collections efforts, resolution of denials, and special billing projects or programs. The auditor ensures compliance with internal protocols, payer regulations, and industry standards.

This role plays a critical part in identifying trends, ensuring accuracy, and improving the overall efficiency and effectiveness of the billing and collections process.

Essential Duties and Responsibilities

• Audit daily work completed by billing staff, including claim submissions, follow-up activities, and collection efforts.
• Review account documentation, actions taken, and billing outcomes within the billing system to ensure accuracy, completeness, and compliance.
• Identify errors, discrepancies, and trends that may impact reimbursement, operational efficiency, or regulatory compliance.
• Provide detailed audit findings, feedback, and recommendations to billing staff and leadership to improve performance and accuracy.
• Monitor, address, and audit special projects (e.g., credit card chargebacks and high priority payer follow up) and programs (e.g., AB75) to ensure adherence to established billing protocols.
• Collaborate with team leads, supervisors, and managers to develop, implement, and refine policies, procedures, and workflows based on audit results.
• Assist with the training and education of staff on documentation standards, payer requirements, billing procedures, and industry best practices.
• Participate in quality assurance initiatives and prepare reports for leadership summarizing audit results, performance trends, and opportunities for improvement.
• Maintain current knowledge of industry regulations, payer policies, and billing software updates applicable to medical billing and accounts receivable.
• Support internal and external audit requests by gathering documentation, performing reviews, and responding to audit inquiries as needed.
• Perform manual tasks within Cross Workflow, including but not limited to AR Support Requests and AR Follow-Up Requests, while addressing high-priority emails from Patient Services related to invoices involving legal representation and time-sensitive deadlines.
• Conduct audits for compliance, as assigned or requested to ensure adherence to company policies, payer guidelines, and regulatory requirements.

Other Duties

Please note this job description is not designed to cover or contain a comprehensive listing of activities, duties or responsibilities that are required of the employee for this job. Duties, responsibilities and activities may change at any time with or without notice.

Requirements

Knowledge, Skills, & Abilities

• Ability to work in a fast-paced environment while maintaining accuracy and focus
• Strong organizational skills to ensure deadlines are met
• Strong knowledge of medical billing and accounts receivable processes, including claim lifecycle, denials, and payer rules.
• Proficient in using billing software and electronic health record (EHR) systems.
• High attention to detail and accuracy in reviewing documentation and financial records.
• Analytical skills with the ability to detect patterns, discrepancies, and areas for improvement.
• Understanding and adhering to HIPAA and other government and healthcare industry regulations.
• Strong written and verbal communication skills to provide constructive feedback and report findings.
• Ability to work independently, manage multiple tasks, and prioritize responsibilities effectively.
• Extensive knowledge of insurance guidelines including Medicare and other government payers, private, self-insurance, and managed-care plans.
• Familiarity with auditing techniques and principles within a healthcare revenue cycle setting.
• Knowledge of MS Office including Outlook, Word and Excel
• Excellent verbal and written communication skills
• Excellent attention to detail and time management skills
• Excellent customer service skills.

Education & Experience Requirements

• High School Diploma
• Minimum 3-4 years revenue cycle experience