RCM Quality Auditor, Charge Entry

About the Role

The RCM Quality Auditor - Charge Entry role involves auditing the work produced by Revenue Cycle Services teams, including coding, charges, claims, payment postings, AR follow-up, and denial work. The goal is to identify and rectify errors before they impact clients financially or create compliance risks. This role requires scoring work accurately and consistently, explaining errors, and assisting teams in resolving underlying issues. The specific audit areas will be determined by the candidate's background and business needs, and may involve auditing multiple areas.

Role Location: In-office

Shift Hours: Monday-Friday, 7:30 PM IST to 4:30 AM IST

Key Responsibilities

• Audit the work:

• Run audits against the approved monthly plan, including random samples, targeted samples (high-dollar accounts, complex specialties or remits, new payers and new clients), and 100% audits for new joiners or associates on a performance improvement plan.

• Validate each audited item against source documents such as superbills, encounter forms, EMR notes, charge logs, ERAs/EOBs, and payer correspondence.

• Verify demographics, insurance, date and place of service, rendering/billing/referring provider, CPT/HCPCS and ICD-10-CM codes and linkage, modifiers, units, charge amounts, and authorization numbers, along with NCCI, MUE, and LCD/NCD requirements.

• Verify billed, allowed, and paid amounts, contractual adjustments, patient responsibility, group and CARC/RARC codes, PLB adjustments, secondary claim triggers, and deposit reconciliation for payment posting.

• Confirm that follow-up actions for AR and denials are correct, documented, and on time; that denials are routed to the correct work queue; and that appeals meet payer requirements.

• Review clearinghouse rejections, scrubber edits, and auto-post exceptions, and confirm fixes were made correctly and on time.

• Flag missed, duplicate, or late charges, suspected underpayments, incorrect write-offs, and unreconciled variances.

• Find the root cause and fix it:

• Classify errors using the approved scoring matrix: critical or non-critical, financial or non-financial, process-based or knowledge-based.

• Provide associates and Team Leads with clear, evidence-backed feedback within 24–48 hours, and track acknowledgment and closure.

• Investigate repeat or high-impact errors, identify the root cause, and assist in building and tracking corrective actions (CAPA) such as retraining, SOP updates, and checklist changes, then verify the effectiveness of the fix.

• Participate in or lead regular calibration sessions with peer auditors, Team Leads, operations, and client QA to ensure scoring consistency.

• Identify skill gaps from audit data, recommend refresher training, assist with onboarding new joiners, and maintain job aids and reference guides.

• Share payer-level patterns, such as denial spikes, recoupments, and underpayments, with AR and Denial Management teams.

• Report, escalate, and stay compliant:

• Maintain complete audit logs, error trackers, feedback sheets, and calibration records, with evidence for every finding in an audit-ready file structure.

• Publish daily, weekly, and monthly quality reports and scorecards at the associate, team, and client level, including RCA reports and trend charts for leadership.

• Escalate critical errors immediately, especially those impacting revenue, compliance, or timely filing.

• Prepare quality summaries and action plans for client quality calls, respond to client quality questions with data and clear timelines, and submit client scorecards on time.

• Adhere to HIPAA, PHI handling standards, CMS rules, and Veradigm information security policies, and support internal and client compliance audits.

• Track annual CPT, HCPCS, and ICD-10-CM updates and payer policy changes, and flag any necessary modifications to SOPs and payer rule references.

• Help improve the process:

• Identify repetitive QA tasks that could be automated and participate in Lean, Six Sigma, and AI-assisted audit pilots.

• Support new client transitions, process documentation, and knowledge assessments.

Qualifications

• Understanding of medical billing and revenue cycle processes.
• Familiarity with coding guidelines and payer requirements.
• Ability to conduct detailed analysis and identify root causes.
• Strong communication skills for providing feedback and reporting.
• Attention to detail and accuracy.
• Knowledge of HIPAA and other relevant healthcare regulations.
• Experience with CPT, HCPCS, and ICD-10-CM coding.
• Experience with payment posting, AR follow-up, and denial management.
• Experience with RCA and CAPA methodologies.
• Experience in data analysis and reporting.
• Experience supporting client interactions and quality calls.

Requirements & Tech Stack

• Source documents include: superbills, encounter forms, EMR notes, charge logs, ERAs/EOBs, and payer correspondence.
• Technical requirements include:
• NCCI
• MUE
• LCD/NCD
• CARC/RARC codes
• PLB adjustments
• Lean
• Six Sigma
• AI-assisted audit