Quality Auditor

Job Description – Auditor (HB & PB)

Role

Auditor – Hospital Billing (HB) & Professional Billing (PB)

Role Summary

Responsible for auditing Hospital Billing (HB) and Professional Billing (PB) accounts with focus on technical and clinical denials, insurance follow-up workflows, Workers’ Compensation (WC), and Third-Party Liability (TPL) processes to ensure accuracy, compliance, and optimal reimbursement.

Key Responsibilities

Perform end-to-end audits of HB and PB accounts including billing, denials, and AR follow-up activities

Review and validate technical denials such as:

Eligibility issues

Demographic errors

Duplicate claims

Timely filing denials

Authorization issues

Provider/NPI-related denials

Review and validate clinical denials such as:

Medical necessity

Diagnosis-procedure linkage

Level of care

Non-covered services

Documentation-related denials

Audit insurance follow-up activities including:

Claim status review

Denial handling

Appeals

Underpayment follow-up

Review and evaluate WC and TPL claims including:

Liability handling

Coordination of benefits

Documentation validation

Validate coding-related denial scenarios involving CPT, ICD-10, modifiers, and payer edits

Conduct root cause analysis (RCA) and identify denial/error trends

Provide actionable feedback and coaching inputs to operations teams

Ensure compliance with payer guidelines, CMS regulations, and client SOPs

Participate in internal/client calibration sessions

Maintain audit accuracy and productivity SLAs

Quality & Governance

Execute random and targeted audits

Ensure audit consistency and inter-rater reliability (IRR)

Track defect trends, denial patterns, and recovery opportunities

Support denial prevention and process improvement initiatives

Qualifications

Bachelor’s degree preferred (Healthcare/RCM preferred)

Certifications preferred: AAPC (CPC/COC) / AHIMA

Experience

5+ years of experience in Revenue Cycle Management (RCM)

Strong exposure to both:

Hospital Billing (HB)

Professional Billing (PB)

Experience in:

Denials management (technical & clinical)

Insurance follow-up

Appeals handling

WC and TPL workflows

Audit / QA activities preferred

Experience with preferred

Skills

Strong understanding of payer guidelines and billing workflows

Knowledge of CPT, ICD-10, modifiers, and denial workflows

Analytical thinking and RCA capability

Strong communication and stakeholder management skills

Ability to identify process gaps and drive quality improvements

We are an Equal Opportunity Employer.  All qualified applicants are considered for employment without regard to race, color, age, religion, sex, sexual orientation, gender identity, national origin, disability, protected veteran status, or any other characteristic protected by federal, state or local law.

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