Job Description Summary :
The RCM Quality Auditor is a critical member of the Revenue Cycle Management quality assurance function, responsible for auditing end-to-end RCM processes including medical coding, claims billing, accounts receivable follow-up, denial management, and payment posting.
This role ensures that all transactions meet required accuracy benchmarks, comply with HIPAA regulations, payer guidelines, and client-specific SOPs. The Quality Auditor serves as the operational backbone of quality governance — identifying defects, performing root cause analyses, supporting corrective actions, and continuously contributing to a culture of excellence across the revenue cycle.
WHAT YOU’LL DO
Quality Auditing
- Audit daily transactions across assigned RCM verticals ( billing, AR, denials, posting) against defined quality parameters
- Perform end-to-end internal audits covering pre-bill, post-bill, and post-payment stages of the revenue cycle
- Validate ICD-10, CPT, and HCPCS codes for accuracy, specificity, and payer-specific compliance rules
- Review claim scrubbing outputs to identify errors prior to submission and flag for correction
- Ensure audit sample size meets the defined monthly audit plan (100% coverage target)
Process Compliance
- Ensure strict adherence to client-specific SOPs, payer guidelines, HIPAA, PHI, and CMS regulations
- Monitor and flag critical compliance errors with zero-tolerance — escalate immediately to Quality Team Leader
- Verify that all claim edits, modifier usage, and medical necessity documentation align with payer contracts
- Support internal compliance audits and provide documentation for regulatory or client reviews
Error Analysis & Root Cause Analysis (RCA)
- Classify errors into defined categories: critical, non-critical, process, and knowledge-based
- Conduct root cause analysis for recurring error patterns and document findings systematically
- Prepare error trend analysis reports on a weekly and monthly basis to highl
📌 RCS Quality Auditor (Pune)
🏢 Veradigm
📍 Pune