Senior Executive - Clinical Auditor
EXL · Chennai
- Review and audit medical claims against patient medical records to ensure accuracy and completeness of documentation.
- Identify discrepancies between clinical documentation and billed services, highlighting variances and potential billing errors.
- Perform detailed clinical reviews to validate diagnosis, procedures, and level of care in accordance with industry standards.
- Ensure compliance with CMS guidelines, payer policies, and regulatory requirements during claim review processes.
- Conduct best practice audits to identify documentation gaps, coding inaccuracies, and revenue leakage opportunities.
- Provide structured findings and audit reports with clear recommendations for corrective action and process improvement.
- Collaborate with coding, billing, and provider teams to resolve audit findings and support accurate claim submissions.
- Monitor trends in audit results and identify recurring issues requiring targeted education or intervention.
- Support quality assurance initiatives by maintaining audit accuracy benchmarks and meeting productivity standards.
- Participate in continuous improvement activities, including updates on CMS regulations, clinical guidelines, and payer policy changes.