RCS Quality Auditor

LE9220 Veradigm India Private Limited - Pune; Pune District; On-site; INR 600,000 - 900,000; Full time

Job summary

LE9220 Veradigm India Private Limited in Pune is seeking an experienced RCM Quality Auditor. This role involves auditing RCM processes including coding, billing, and denial management, ensuring compliance with HIPAA and payer guidelines.

The ideal candidate will have a Bachelor's degree, at least 5 years of experience in RCM quality auditing, and proficiency in ICD-10, CPT, and HCPCS coding standards. A strong analytical mind and attention to detail are essential.

Qualifications

• 5 years of experience in RCM quality auditing, including payment and billing.
• BPO/KPO healthcare background is a plus.
• Six Sigma certification preferred, required within 12 months if not already held.

Responsibilities

• Audit daily RCM transactions against quality parameters.
• Perform internal audits covering all stages of the revenue cycle.
• Validate coding accuracy and compliance rules.

Skills

ICD-10-CM proficiency

CPT proficiency

HCPCS Level II proficiency

Analytical thinking

Attention to detail

Communication skills

Education

Bachelor's degree in any discipline

Healthcare Management or Life Sciences preferred

Tools

MS Excel

QA dashboards

Job description

Job Description Summary

The RCM Quality Auditor is a critical member of the Revenue Cycle Management quality assurance function, responsible for auditing end-to-end RCM processes including medical coding, claims billing, accounts receivable follow-up, denial management, and payment posting. This role ensures that all transactions meet required accuracy benchmarks, comply with HIPAA regulations, payer guidelines, and client-specific SOPs. The Quality Auditor serves as the operational backbone of quality governance – identifying defects, performing root cause analyses, supporting corrective actions, and continuously contributing to a culture of excellence across the revenue cycle.

What You’ll Do

• Audit daily transactions across assigned RCM verticals (billing, AR, denials, posting) against defined quality parameters
• Perform end-to-end internal audits covering pre-bill, post-bill, and post-payment stages of the revenue cycle
• Validate ICD-10, CPT, and HCPCS codes for accuracy, specificity, and payer-specific compliance rules
• Review claim scrubbing outputs to identify errors prior to submission and flag for correction
• Ensure audit sample size meets the defined monthly audit plan (100% coverage target)
• Ensure strict adherence to client-specific SOPs, payer guidelines, HIPAA, PHI, and CMS regulations; monitor and flag critical compliance errors with zero-tolerance and elevate immediately to the Quality Team Leader
• Verify that all claim edits, modifier usage, and medical necessity documentation align with payer contracts
• Support internal compliance audits and provide documentation for regulatory or client reviews
• Classify errors into critical, non‑critical, process, and knowledge‑based categories; conduct root cause analysis for recurring patterns and document findings; prepare weekly and monthly trend reports; track corrective action plan implementation and verify effectiveness
• Identify skill gaps from audit data, conduct targeted one‑on‑one feedback sessions, support the Quality Team Leader in designing training, conduct calibration sessions, and create error‑specific reference guides and job aids
• Prepare daily, weekly, and monthly MIS reports, dashboards, and scorecards; maintain audit logs, error trackers, feedback sheets, and calibration records; generate RCA reports, corrective action logs, and quality trend charts for leadership review
• Participate in Lean, Six Sigma, and automation‑driven improvement initiatives across RCM; identify manual and repetitive tasks for automation; pilot technology solutions with IT and operations; benchmark internal standards against industry leaders and recommend improvements
• Prepare quality summary reports, audit findings, and action plans for client quality calls; assist in responding to client quality queries with data‑backed responses and corrective timelines; maintain client‑facing scorecards and ensure timely submission per contractual timelines

What We’re Looking For

Education & Experience

• Bachelor’s degree in any discipline; Healthcare Management or Life Sciences preferred
• 5 years of experience in RCM quality auditing (payment, billing, AR, denials, patient calling)
• BPO / KPO healthcare background is a plus

Certifications

• Six Sigma certification preferred; required within 12 months of joining if not already held
• CPC, CRC, CPMA, CCS, RHIT, or equivalent coding/billing certification preferred

Technical Skills

• Proficiency in ICD-10-CM, CPT, HCPCS Level II; familiarity with NCCI edits and LCD/NCD guidelines
• Working knowledge of Medicare, Medicaid, and commercial payer billing and audit guidelines
• Strong understanding of HIPAA, PHI, CMS regulations, and patient data privacy requirements
• Experience with EMR/PMS systems; proficiency in MS Excel and QA dashboards

Soft Skills

• Strong analytical thinking and exceptional attention to detail
• Excellent verbal and written communication skills
• Effective feedback delivery and coaching abilities
• Knowledge of denial trends, AR aging, and revenue recovery processes is a strong advantage

Visa Sponsorship is not offered for this position.

Applicants for North American based positions with Veradigm must be legally authorized to work in the United States or Canada. Verification of employment eligibility will be required as a condition of hire.

Veradigm’s policy is to provide equal employment opportunity and affirmative action in all of its employment practices without regard to race, color, religion, sex, national origin, ancestry, marital status, protected veteran status, age, individuals with disabilities, sexual orientation or gender identity, or any other legally protected category.