Reviews medical claims against patient records to validate diagnoses, procedures, documentation, coding, billing accuracy, and compliance with CMS, payer, and regulatory requirements. Identifies discrepancies, revenue leakage, and recurring audit issues; prepares findings and corrective recommendations; collaborates with coding, billing, and provider teams; supports quality assurance, process improvement, regulatory updates, and productivity targets.
- 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
EXL Chennai, Tamil Nadu, IND Office
Chennai, India
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