Quality Analyst – Medical Billing/RCM

1 week ago

Shimoga, Karnataka, India Arrow Full time

Medical Billing Quality Auditor - REMOTE

Position Overview

The Medical Billing Quality Auditor ensures accuracy, compliance, and efficiency in the revenue cycle process by reviewing claims, payments, denials, and related workflows. This role is critical to maintaining high-quality standards for U.S. healthcare clients by monitoring billing, coding, AR calling, and credentialing activities, identifying errors, and recommending corrective actions.

Key Responsibilities

  • Quality Assurance & Audit
  • Audit medical billing claims, payment posting, denials management, AR follow-ups, and credentialing tasks against company SOPs and client guidelines.
  • Review claims for accuracy in patient demographics, insurance details, CPT/ICD coding, modifiers, and charge entry.
  • Monitor adherence to HIPAA and U.S. healthcare compliance requirements.
  • Conduct random and targeted audits on AR calling notes, eligibility checks, and credentialing packets.
  • Error Identification & Corrective Action
  • Identify trends in errors (e.g., data entry mistakes, coding mismatches, underpayments).
  • Provide feedback and detailed audit reports to operations managers and team leads.
  • Suggest corrective measures, retraining needs, or process improvements.
  • Performance Monitoring
  • Track team KPIs like First Pass Resolution Rate (FPRR), Clean Claim Rate, Denial Rate, and AR Days.
  • Evaluate compliance with SLAs (turnaround times, accuracy percentages).
  • Work with training teams to design refresher modules for billers and AR callers.
  • Documentation & Reporting
  • Maintain accurate audit logs, scorecards, and quality dashboards.
  • Present weekly/monthly audit summaries with trend analysis.
  • Collaborate with client-side quality teams to ensure alignment with expectations.

Qualifications

  • Bachelor's degree (preferably in healthcare, life sciences, or commerce).
  • 3–5 years' experience in medical billing, coding, running reports or AR calling; minimum of 1–2 years in quality audit.
  • Strong knowledge of U.S. healthcare revenue cycle (charge entry, payment posting, denials, AR follow-up, credentialing, reporting).
  • Familiarity with CPT, ICD-10, HCPCS codes, and payer-specific guidelines.
  • Proficiency in MS Excel, quality tracking tools, and EMR/billing software (e.g., DrChronos, AdvancedMD, Simple Practice, Therapy Notes, Athena, Epic).

Key Skills

  • Excellent attention to detail and analytical ability.
  • Strong written and verbal communication (English proficiency required).
  • Ability to identify patterns/trends and provide actionable insights.
  • Knowledge of HIPAA regulations and compliance requirements.
  • Process-oriented mindset with problem-solving skills.

Performance Metrics

  • Accuracy rate in audited claims (> 98%).
  • Reduction in denials and rework through early detection.
  • Timely submission of audit reports.
  • Contribution to team performance improvement and SLA adherence.

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