Job Title: Quality Assurance (QA) Analyst / QA Auditor US Healthcare RCM

Position Summary:

The QA Analyst/Auditor is responsible for ensuring quality, accuracy, and compliance across all Revenue Cycle Management (RCM) processes including Medical Billing, Medical Coding, Accounts Receivable (AR) Management, Denial Management, and Payment Posting. This role involves performing detailed audits, identifying process gaps, training teams for improvement, and generating actionable reports to maintain high operational standards. The ideal candidate should possess deep AR follow-up knowledge, a strong understanding of Medical Billing & Coding workflows, and expertise in US healthcare payer regulations.

Key Responsibilities:

1. Quality Auditing & Monitoring:

- Perform end-to-end audits on RCM processes (Demographics, Charge Entry, Coding, Billing, AR follow-up, Payment Posting, Denials, Appeals).
- Evaluate coding accuracy (ICD-10, CPT, HCPCS) ensuring alignment with payer guidelines and compliance standards.
- Identify errors, process deviations, or non-compliance issues and provide root-cause analysis.
- Develop and implement quality checklists, audit templates, and sampling methodologies for different process lines.
- Monitor team performance through transaction audits, accuracy scores, and trend analysis.

2. AR & Denial Management Expertise:

- Conduct deep-dive AR analysis to track outstanding claims, payer trends, and resolution timelines.
- Audit denied claims, identify root causes, and recommend corrective actions to improve first-pass resolution rate (FPRR).
- Ensure AR follow-up agents adhere to payer-specific guidelines, timely follow-ups, and compliance standards.
- Track and analyze Days in AR, collections efficiency, and write-off patterns.

3. Compliance & Certification Standards:





- Ensure all RCM activities are compliant with HIPAA, OIG, CMS, and payer-specific requirements.
- Validate coding compliance using AAPC/AHIMA coding guidelines.
- Recommend and enforce internal SOPs based on latest regulatory updates.

4. Reporting & Analytics:

- Prepare comprehensive QA reports (daily/weekly/monthly) highlighting accuracy trends, error patterns, and team performance.
- Develop dashboards & KPIs for leadership (accuracy %, compliance %, AR days, denial trends, productivity metrics).
- Present audit findings with data-backed actionable insights to Operations and Client Management teams.
- Track rework costs and productivity loss due to quality issues and recommend preventive measures.

5. Training & Continuous Improvement:

- Conduct refresher training sessions for Medical Billing, AR, and Coding teams based on audit findings.
- Partner with operations leads to design Corrective and Preventive Action (CAPA) plans.
- Build and maintain a knowledge repository of payer policies, denial codes, and coding changes.
- Support process re-engineering initiatives to drive higher quality and efficiency.

Required Skills & Competencies:

Technical/Domain Expertise:

- Robust knowledge of US Healthcare RCM end-to-end workflow, including:
- Patient Demographics, Insurance Eligibility & Verification
- Medical Billing & Claim Submission (CMS-1500/1450)
- AR Follow-up & Denial Management
- Payment Posting & Adjustments
- Medical Coding (ICD-10, CPT, HCPCS)





- Proficiency in EHR/EMR and RCM systems (Epic, eClinicalWorks, AdvancedMD, Kareo, Athenahealth, or equivalent).
- Hands-on experience with payer portals and clearinghouses (Availity, Change Healthcare, Optum, etc.).
- Strong understanding of payer rules (Medicare, Medicaid, Commercial payers).

Quality & Analytical Skills:

- Advanced auditing and quality assessment skills.
- Strong data analytics capability to identify trends and variances.
- Proficiency in Excel, MS Access, Power BI/Tableau for reporting and dashboards.
- Familiarity with Six Sigma / Lean quality tools (preferred).

Soft Skills:

- Strong attention to detail and ability to work with minimal supervision.
- Excellent communication and presentation skills (both written and verbal).
- Ability to handle multiple priorities, tight deadlines, and a dynamic work environment.
- Collaborative approach with Operations, Clients, and Training teams.

Certifications (preferred/mandatory based on client requirement):

- AAPC (CPC, CRC, CPMA, or equivalent)
- AHIMA (CCS, CCA, or equivalent)
- CMRS (Certified Medical Reimbursement Specialist)
- HFMA CRCP/CRCS (advantage)
- Lean Six Sigma Green Belt/Yellow Belt (preferred for process improvement)

Experience:

- 36 years of experience in US Healthcare RCM industry.
- Minimum 2 years in QA or Audit role.
- Hands-on experience in AR follow-up, Denials, and Medical Coding audit
- Client-facing experience and exposure to offshore delivery models (preferred).

Performance Metrics (KPIs):

- Audit Accuracy Score (Target > 98%)
- First Pass Resolution Rate (FPRR) improvement
- Reduction in AR days and Denial rates
- Timeliness and accuracy of QA reporting
- Compliance adherence (HIPAA, coding guidelines)

📌 Quality Assurance (QA) Analyst and Auditor, US Healthcare RCM (Hyderabad)
🏢 Dolluz Corporation Private
📍 Hyderabad