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 highlight systemic issues
- Track corrective action plan (CAP) implementation and verify effectiveness post-correction

Training Coaching

- Identify skill gaps from audit data and conduct targeted one-on-one feedback sessions
- Support the Quality Team Leader in designing and delivering refresher training programs
- Conduct calibration sessions with operations staff to align understanding of quality standards
- Create and maintain error-specific reference guides and job aids for operations teams

Reporting Documentation

- Prepare and submit daily, weekly, and monthly quality MIS reports, dashboards, and scorecards
- Maintain up-to-date audit logs, error trackers, feedback sheets, and calibration records
- Document all audit findings with evidence and maintain an organized, audit-ready file system
- Generate RCA reports, corrective action logs, and quality trend charts for leadership review

Process Improvement

- Participate in Lean, Six Sigma, and automation-driven improvement initiatives across RCM
- Identify manual and repetitive quality tasks that can be streamlined through automation or technology
- Collaborate with IT and operations teams to pilot quality improvement technologies (e.g., AI auditing tools)




- Benchmark internal quality standards against industry leaders and recommend improvements

Client /Stake holder Interaction

- Prepare quality summary reports, audit findings, and action plans for client quality calls
- Assist in responding to client quality queries with data-backed responses and corrective timelines
- Maintain client-facing quality scorecards and ensure timely submission per contractual timelines

WHAT WE LOOKING FOR

Education Experience

- Bachelor s degree in any discipline; Healthcare Management or Life Sciences preferred
- 5 years of experience in RCM quality auditing (payment, Billing, AR, Denials patient calling)
- BPO / KPO healthcare background is a plus

Certifications

- Six sigma certification preferrable
- Certification required within 12 months of joining if not already held
- CPC, CRC, CPMA, CCS, RHIT, or equivalent coding/billing certification preferrable

Technical Skills

- Proficiency in ICD-10-CM, CPT, HCPCS Level II; familiarity with NCCI edits and LCD/NCD guidelines
- Working knowledge of Medicare, Medicaid, and commercial payer billing and audit guidelines
- Strong understanding of HIPAA, PHI, CMS regulations, and patient data privacy requirements
- Experience with EMR/PMS systems proficiency in MS Excel and QA dashboards

Soft Skills

- Strong analytical thinking and exceptional attention to detail
- Excellent verbal and written communication skills
- Effective feedback delivery and coaching abilities
- Knowledge of denial trends, AR aging, and revenue recovery processes is a robust advantage

Disclaimer : This job posting has been aggregated from external source. Role details, content, and availability are subject to change. Applicants are advised to confirm the latest information directly on the company website before applying.

📌 RCS Quality Auditor (Pune)
🏢 Allscripts(India) LLP, ultimately a subsidiary of Altera Digital Health Inc.,[Altera India]
📍 Pune