Medical Auditor

Role Summary:

Medical Auditor is responsible for reviewing medical records to ensure accuracy, completeness, and compliance with applicable laws, regulations, and standards.

Medical Auditor will analyze medical documents to identify errors or irregularities, and make recommendations for corrective action.

Medical Auditor also provide education to medical staff on proper documentation and compliance.

Primary Responsibilities:

1.   Review medical records and associated documentation to ensure they are complete, accurate, and compliant with relevant regulations.

2.   The Medical Auditor is responsible for performing detailed audits of medical records and other data to identify errors and inaccuracies, and to assess the accuracy of claims submitted for payment.

3.   The auditor will also provide guidance and assistance to medical providers on how to improve their documentation and coding practices.

4.   The ultimate goal is to ensure that all medical services are properly documented, coded, and billed in order to maximize reimbursement and minimize fraud and abuse.

5.   Analyze medical data for cost efficiency and appropriateness of care

6.   Properly audit all type of claims from the medical and insurance perspective.

7.   Assure meeting the daily assigned target in terms of quantity & quality.

8.   Report back any type of claims observation or issues that may affect the process.

9.   Participate in developing the billing system by providing new ideas or proposal in order to enhance the process.

10. Contribute in developing, updating and implementing the guidelines for evaluation and processing of medical claims, as well as policies and procedures and work instructions related to medical claims review and processing.

11. Gather relevant information to clearly describe and properly escalate issues to insurance manager.

12. Ensure that business decisions and processes are documented in a professional way and the communication requirements are being adhered to in a timely and professional manner.

13. Conduct training to improve the technical, insurance and medical skills and knowledge for team members as assigned by insurance manager.

14. Provide all the needed support as advised by insurance manager based on the business need.

15. Other related tasks assigned by the line manager

Skills

Job Requirements:

·        Bachelor’s Degree in Medicine (MBBS) or any Bachelor’s degree in the medical/life science field.

·        Must have an in-depth understanding of medical coding and billing procedures, as well as a thorough understanding of applicable laws, regulations, and guidelines.

·        At least 1 year medical auditing experience with a provider / payer/ TPA is essential.

·        Good knowledge of insurance protocols.

·        Should have good IT skills.

·        Knowledge of ICDs, CPTs is preferable

Key Performance Indicators (KPI's)

·        To follow business rules / coding and billing guidelines -100%.

·        Complete the targets as designated within the TAT