RCM Quality Auditor

About the Role

The RCM Quality Auditor checks the work produced by Revenue Cycle Services teams, including coding, charges, claims, payment postings, AR follow-up, and denial work. The role aims to catch errors before they impact clients financially or create compliance risks. The auditor will score work fairly, explain errors, and help teams resolve underlying problems. The audit area will depend on background and business needs, potentially covering multiple areas.

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, 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 coding and charge entry details including demographics, insurance, date and place of service, rendering/billing/referring provider, CPT/HCPCS and ICD-10-CM codes and linkage, modifiers, units, charge amounts, authorization numbers, along with NCCI, MUE, and LCD/NCD requirements.
• Verify payment posting details including billed, allowed, and paid amounts, contractual adjustments, patient responsibility, group and CARC/RARC codes, PLB adjustments, secondary claim triggers, and deposit reconciliation.
• Confirm AR and denials follow-up actions are correct, documented, and timely; denials land in the right work queue; and 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 clear, evidence-backed feedback within 24–48 hours, and track acknowledgment and closure.
• Investigate repeat or high-impact errors, find the root cause, and help build and track corrective actions (CAPA) such as retraining, SOP updates, and checklist changes. Verify the fix's effectiveness.
• Participate in or lead regular calibration sessions with peer auditors, Team Leads, operations, and client QA to ensure consistent and defensible scoring.
• 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 each finding in an audit-ready file structure.
• Publish daily, weekly, and monthly quality reports and scorecards at associate, team, and client levels, 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, answer 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 at all times, and support internal and client compliance audits.
• Track annual CPT, HCPCS, and ICD-10-CM updates and payer policy changes, and flag any necessary changes to SOPs and payer rule references.
• Help improve the process:
• Identify repetitive QA tasks for potential automation and participate in Lean, Six Sigma, and AI-assisted audit pilots.
• Support new client transitions, process documentation, and knowledge assessments.

Requirements & Tech Stack

• In-office role with shift hours Monday-Friday, 7:30 PM IST to 4:30 AM IST.
• Familiarity with HIPAA, CMS rules, and information security policies.

Qualifications

• Experience auditing coding, charges, claims, payment posting, AR follow-up, and denial work.
• Experience with source document validation (superbills, encounter forms, EMR notes, charge logs, ERAs/EOBs, payer correspondence).
• Proficiency in verifying coding and charge entry details, including CPT/HCPCS, ICD-10-CM, modifiers, NCCI, MUE, and LCD/NCD.
• Experience verifying payment posting details, including CARC/RARC codes, PLB adjustments, and reconciliation.
• Experience with AR and denials processes, including follow-up actions and appeals.
• Experience reviewing clearinghouse rejections, scrubber edits, and auto-post exceptions.
• Ability to perform root cause analysis.
• Experience with quality assurance reporting and documentation.
• Ability to provide clear, evidence-based feedback.
• Experience with calibration sessions.
• Understanding of payer policies and updates.