Senior Executive - Claims Audit

Job Description

• 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.