Senior Executive - Clinical Auditor

Ex; Chennai District; On-site; INR 600,000 - 900,000; Full time

Job summary

Ex in Chennai, India is seeking a detail-oriented Medical Claims Auditor to review and audit medical claims against patient records, ensuring documentation is accurate and complete. You will identify discrepancies between clinical documentation and billed services, and validate diagnosis and procedures for coding accuracy.

Work includes ensuring compliance with CMS guidelines, payer policies, and regulatory requirements, conducting best-practice audits, and collaborating with coding and billing

Responsibilities

• Review medical claims against patient records to ensure documentation accuracy.
• Identify discrepancies between documentation and billed services.
• Perform clinical reviews to validate diagnoses and procedures.
• Ensure CMS, payer policies and regulatory compliance in reviews.
• Audit for documentation gaps, coding inaccuracies, and leakage.
• Provide findings and reports with corrective action recommendations.
• Collaborate with coding, billing, and provider teams to resolve findings.
• Monitor audit trends and flag recurring issues for education.
• Support QA by maintaining accuracy benchmarks and productivity.
• Contribute to continuous improvement, CMS updates and policy changes.

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.