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.

Senior Clinical Auditor

Key skills