Medical Billing Compliance Specialist

4 days ago

Belgaum, Karnataka, India beBeeCompliance Full time ₹ 20,00,000 - ₹ 35,00,000
Medical Billing Quality Auditor

A Medical Billing Quality Auditor is a critical role in ensuring the accuracy, compliance, and efficiency of the revenue cycle process.

The auditor reviews claims, payments, denials, and related workflows to ensure high-quality standards for U.S. healthcare clients. They monitor billing, coding, AR calling, and credentialing activities, identifying errors and recommending corrective actions.

Key Responsibilities:

  • Quality Assurance & Audit
  • Review medical billing claims against company SOPs and client guidelines.
  • Check patient demographics, insurance details, CPT/ICD coding, modifiers, and charge entry for accuracy.
  • 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 in healthcare, life sciences, or commerce.
  • 3-5 years' experience in medical billing, coding, running reports or AR calling; minimum 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.

Required Skills:

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

Benefits:

  • 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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