Medical Claim Auditor

We are seeking a detail-oriented Claims Auditor to oversee the accuracy and integrity of patient hospitalization claims. In this role, you will be the final line of defense in ensuring that clinical documentation aligns with billed services, insurance policies, and regulatory standards. Your goal is to minimize leakages, prevent fraud, and ensure a seamless financial journey for both the patient and the healthcare provider.

​Key Responsibilities

​Clinical Record Review: Perform a deep-dive audit of inpatient records, including discharge summaries, operative notes, and nursing charts, to verify the necessity of the hospitalization.

​Financial Reconciliation: Cross-reference clinical procedures with the final bill to ensure all charges are supported by documented medical evidence.

​Policy Compliance: Validate claims against specific insurance policies, TPA (Third Party Administrator) guidelines, and government health schemes.

​Discrepancy Resolution: Identify and flag "unbundling" of services, upcoding, or billing for services not rendered.

​Reporting: Prepare detailed audit reports highlighting findings, recovery amounts, and patterns of recurring errors to help improve future billing cycles.

​Stakeholder Liaison: Communicate with the medical coding team, doctors, and insurance companies to clarify documentation gaps.

​Required Skills & Qualifications

​Educational Background: A degree in Nursing (B.Sc/GNM), Pharmacy (B.Pharm), or Life Sciences is typically required. Certification in Medical Coding (CPC/CCS) is a major plus.

​Technical Expertise: * Strong understanding of ICD-10, CPT, and HCPCS coding systems.

​Familiarity with medical terminology and hospital billing workflows.

​Proficiency in Hospital Information Systems (HIS) and Excel.

​Analytical Mindset: An eagle eye for detail and the ability to spot inconsistencies in high-volume data.

​Ethics: High integrity, as you will be handling sensitive patient data (HIPAA compliance).

​Preferred Experience

​2+ years of experience in a TPA, Health Insurance company, or a Hospital’s Billing/Audit department.

​Specific experience handling Inpatient (IPD) claims, as they are significantly more complex than outpatient claims.

​Success Metrics

​Audit Accuracy Rate: Maintaining a 98% or higher accuracy in claim reviews.

​Turnaround Time (TAT): Completing audits within the defined window to avoid payment delays.

​Leakage Prevention: Identifying a target percentage of cost savings through the detection of billing errors.