Senior Executive - Claims Audit

• Review and analyze medical records and claims data to ensure accuracy, completeness, and compliance with healthcare regulations and payer requirements.

• Verify that all necessary clinical documentation is included to support claim submissions and medical necessity.

• Identify and resolve inconsistencies, errors, or missing documentation in patient records or claims.

• Prioritize and manage workloads to ensure expedited and high-priority cases are processed within defined timelines.

• Collaborate with healthcare providers, coders, and billing staff to obtain or clarify necessary information.

• Ensure compliance with HIPAA, CMS, and other regulatory guidelines related to medical record handling and claims processing.

• Prepare accurate reports and summaries of claim findings, trends, and potential process improvements.

• Support internal audits and quality assurance initiatives by providing detailed documentation and analytical insights.

• Maintain a strong understanding of healthcare terminology, coding standards (ICD, CPT, HCPCS), and insurance claim procedures.

Responsibilities:

Complete the necessary training and meet the expectations outlined for the position.

Follow all standard operating procedures (SOP) diligently.

Complete audits promptly and ensure high quality.

Strive to meet both quality and production targets.

Adhere to project protocols and instructions.

Report any issues or trends promptly.