Quality Auditor

Job Description - Auditor (HB & PB)

Role

Auditor - Hospital Billing (HB) & Professional Billing (PB)

Role Summary

Responsible for auditing Hospital Billing (HB) and Professional Billing (PB) accounts with focus on technical and clinical denials, insurance follow-up workflows, Workers' Compensation (WC), and Third-Party Liability (TPL) processes to ensure accuracy, compliance, and optimal reimbursement.

Key Responsibilities

• Perform end-to-end audits of HB and PB accounts including billing, denials, and AR follow-up activities

• Review and validate technical denials such as:

  • Eligibility issues

  • Demographic errors

  • Duplicate claims

  • Timely filing denials

  • Authorization issues

  • Provider/NPI-related denials

• Review and validate clinical denials such as:

  • Medical necessity

  • Diagnosis-procedure linkage

  • Level of care

  • Non-covered services

  • Documentation-related denials

• Audit insurance follow-up activities including:

  • Claim status review

  • Denial handling

  • Appeals

  • Underpayment follow-up

• Review and evaluate WC and TPL claims including:

  • Liability handling

  • Coordination of benefits

  • Documentation validation

• Validate coding-related denial scenarios involving CPT, ICD-10, modifiers, and payer edits

• Conduct root cause analysis (RCA) and identify denial/error trends

• Provide actionable feedback and coaching inputs to operations teams

• Ensure compliance with payer guidelines, CMS regulations, and client SOPs

• Participate in internal/client calibration sessions

• Maintain audit accuracy and productivity SLAs

Quality & Governance

• Execute random and targeted audits

• Ensure audit consistency and inter-rater reliability (IRR)

• Track defect trends, denial patterns, and recovery opportunities

• Support denial prevention and process improvement initiatives

Qualifications

• Bachelor's degree preferred (Healthcare/RCM preferred)

• Certifications preferred: AAPC (CPC/COC) / AHIMA

Experience

• 5+ years of experience in Revenue Cycle Management (RCM)

• Strong exposure to both:

  • Hospital Billing (HB)

  • Professional Billing (PB)

• Experience in:

  • Denials management (technical & clinical)

  • Insurance follow-up

  • Appeals handling

  • WC and TPL workflows

  • Audit / QA activities preferred

• Experience with preferred

Skills

• Strong understanding of payer guidelines and billing workflows

• Knowledge of CPT, ICD-10, modifiers, and denial workflows

• Analytical thinking and RCA capability

• Strong communication and stakeholder management skills

• Ability to identify process gaps and drive quality improvements

We are an Equal Opportunity Employer. All qualified applicants are considered for employment without regard to race, color, age, religion, sex, sexual orientation, gender identity, national origin, disability, protected veteran status, or any other characteristic protected by federal, state or local law.


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