PUNE · FULLTIME
RCM Quality Auditor
Altera Digital Health
Pune · onsite · Posted 1d ago
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Undisclosed2–5 yrsfulltimePune
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Section · 01
About this role
In Office - Shift Hours M-F 730pm IST to 430am IST
The RCM Quality Auditor checks the work our Revenue Cycle Services teams produce, including coding, charges, claims, payment postings, AR follow-up and denial work, and catches errors before they cost our clients money or create compliance risk.
The role will score work fairly and consistently, explain clearly what went wrong and why, and help teams fix the underlying problem so it doesnt keep happening. The area you audit will depend on your background and where the business needs coverage, and you may audit more than one.
Audit the work
- Audit plan: 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.
- Source checks: Validate each audited item against source documents such as superbills, encounter forms, EMR notes, charge logs, ERAs/EOBs and payer correspondence.
- Coding and charge entry: 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 authorisation numbers, along with NCCI, MUE and LCD/NCD requirements.
- Payment posting: Verify billed, allowed and paid amounts, contractual adjustments, patient responsibility, group and CARC/RARC codes, PLB adjustments, secondary claim triggers and deposit reconciliation.
- AR and denials: Confirm that follow-up actions are correct, documented and on time, that denials land in the right work queue, and that appeals meet payer requirements.
- Rejections and exceptions: Review clearinghouse rejections, scrubber edits and auto-post exceptions, and confirm fixes were made correctly and on time.
- Gaps and leakage: 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.
- Feedback: Give associates and Team Leads clear, evidence-backed feedback within 24-48 hours, and track that it is acknowledged and closed.
- Root cause analysis: Dig into 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. Then check that the fix worked.
- Calibration: Run or join regular calibration sessions with peer auditors, Team Leads, operations and client QA so scoring stays consistent and defensible.
- Training support: Spot skill gaps from audit data, recommend refresher training, help onboard new joiners, and keep job aids and reference guides current.
- Trends: Share payer-level patterns, such as denial spikes, recoupments and underpayments, with the AR and Denial Management teams.
Report, escalate and stay compliant
- Records: Keep audit logs, error trackers, feedback sheets and calibration records complete, with evidence for every finding in an audit-ready file structure.
- Reporting: Publish daily, weekly and monthly quality reports and scorecards at associate, team and client level, including RCA reports and trend charts for leadership.
- Escalation: Escalate critical errors right away, especially anything with revenue, compliance or timely filing impact.
- Client support: 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.
- Compliance: Follow HIPAA, PHI handling standards, CMS rules and Veradigm information security policies at all times, and support internal and client compliance audits.
- Staying current: Track annual CPT, HCPCS and ICD-10-CM updates and payer policy changes, and flag any needed changes to SOPs and payer rule references.
Help improve the process
- Automation: Point out repetitive QA tasks that could be automated, and take part in Lean, Six Sigma and AI-assisted audit pilots.
- Transitions: Support new client transitions, process documentation and knowledge assessments.
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.
Sourced from naukri
Section · 02
Skills
AutomationCMScharge entryhcpcsAws EmrclassificationauditsPayment PostingDenial ManagementhipaaCAPACompliance RiskClient Supportmodifiersperformance improvement planInformation SecurityoperationscomplianceArtificial Intelligence
Section · Company
About Altera Digital Health
Altera Digital Health
Software Product
2.3k+
employees
2022
4 years old
London
GB
About
Altera Digital Health develops IT solutions aimed at enhancing clinician experience and improving overall healthcare service delivery.
Industries
Software Product
Employee ratings
296 reviews
3.1/ 5
Culture
3.1
Career growth
2.3
Work-life
3.4
Employees rate it well for
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