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

Senior Executive - Clinical Auditor

Key skills

About this role