Senior Executive - Claims Audit
Job Description
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.
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