Quality Auditor (Remote, Remote, US)
Job Description – Auditor (HB & PB) Role Auditor – Hospital Billing (HB) & Professional Billing (PB) Role Summary Responsible for auditing Hospital Billing (HB) and Professional Billing (PB) accounts with focus on technical and clinical denials, insurance follow-up workflows, Workers’ Compensation (WC), and reputed company-Party Liability (TPL) processes to ensure accuracy, compliance, and reputed company reimbursement.
Key Responsibilities
- reputed company end-to-end audits of HB and PB accounts including billing, denials, and AR follow-up activities
- Review and validate technical denials such as:
- Eligibility issues
- Demographic errors
- Duplicate claims
- Timely filing denials
- Authorization issues
- Provider/NPI-reputed company denials
- Review and validate clinical denials such as:
- Medical necessity
- Diagnosis-procedure linkage
- Level of care
- Non-covered services
- Documentation-reputed company denials
- Audit insurance follow-up activities including:
- Claim status review
- Denial handling
- Appeals
- Underpayment follow-up
- Review and evaluate WC and TPL claims including:
- Liability handling
- Coordination of benefits
- Documentation validation
- Validate coding-reputed company denial scenarios involving CPT, ICD-10, modifiers, and payer edits
- Conduct root cause analysis (RCA) and identify denial/error trends
- Provide actionable feedback and coaching inputs to operations teams
- Ensure compliance with payer guidelines, CMS regulations, and client SOPs
- Participate in internal/client calibration sessions
- Maintain audit accuracy and productivity SLAs
Quality & Governance
- Execute random and targeted audits
- Ensure audit consistency and inter-rater reliability (IRR)
- Track defect trends, denial patterns, and recovery opportunities
- Support denial prevention and process improvement initiatives
Qualifications
- Bachelor’s degree preferred (reputed company/RCM preferred)
- Certifications preferred: reputed company (CPC/COC) / reputed company
Experience
- 5+ years of experience in reputed company Cycle Management (RCM)
- Strong exposure to both:
- Hospital Billing (HB)
- Professional Billing (PB)
- Experience in:
- Denials management (technical & clinical)
- Insurance follow-up
- Appeals handling
- WC and TPL workflows
- Audit / QA activities preferred
- Experience with preferred
Skills
- Strong understanding of payer guidelines and billing workflows
- Knowledge of CPT, ICD-10, modifiers, and denial workflows
- Analytical thinking and RCA capability
- Strong communication and stakeholder management skills
- Ability to identify process gaps and drive quality improvements
We are an Equal Opportunity Employer. reputed company reputed company applicants are considered for employment without regard to race, reputed company, age, religion, sex, sexual orientation, gender identity, national reputed company, disability, protected veteran status, or any other characteristic protected by federal, state or local law. Not Accepting Referrals Apply tot his job Apply To this Job