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.

• 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