RCM Quality Auditor

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Responsibilities

• In Office - Shift Hours M-F 730pm IST to 430am IST About the role: The RCM Quality Auditor - AR & Denials checks the AR follow-up, denial and rejection work our Revenue Cycle Services teams produce and catches errors before they cost our clients money or create compliance risk.
• You will score work fairly and consistently, explain clearly what went wrong and why, and help teams fix the underlying problem so it does not keep happening.
• Qualifications 2 to 4 years of US healthcare revenue cycle experience in AR follow-up, denial management or AR QA.
• Strong working knowledge of CARC/RARC codes, payer appeal processes, timely filing limits, and payer portal and IVR follow-up.
• Familiarity with clearinghouse rejections, scrubber edits and common front-end denial causes (eligibility, authorization, registration).
• Audit the work Audit plan.
• Run audits against the approved monthly plan, including random samples, targeted samples (high-dollar accounts, complex specialties, new payers and new clients) and 100% audits for new joiners or associates on a performance improvement plan.
• Source checks.
• Validate each audited account against claim history, ERAs/EOBs, payer portal and call records, and payer correspondence.
• Follow-up quality.
• Confirm that follow-up actions are correct, documented and on time, that account notes are clear enough for the next person to act on, and that next-action dates are set appropriately.
• Denials and appeals.
• Confirm that denials land in the right work queue, that the corrective action matches the denial reason, and that appeals and reconsiderations meet payer requirements and filing limits.
• Rejections and edits.
• Review clearinghouse rejections and scrubber edits, and confirm fixes were made correctly and on time.
• Gaps and leakage.
• Flag incorrect write-offs and adjustments, missed timely filing or appeal deadlines, unworked underpayments and accounts closed without resolution.
• Find the root cause and fix it 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.
• Training support.
• Spot skill gaps from audit data, recommend refresher training, help onboard new joiners, and keep job aids and payer reference guides current.
• Trends.
• Share payer-level patterns, such as denial spikes, recoupments and preventable front-end denials, with operations, AR and Denial Management leadership.
• Report, escalate and stay compliant 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.
• Staying current.
• Track payer policy changes, appeal and timely filing rules, and annual code updates, and flag needed changes to SOPs and payer rule references.
• Transitions.
• Support new client transitions, process documentation and knowledge assessments.

Requirements

• Excel skills and clear written English for feedback and client-facing summaries.

Preferred

• experience with Medicare, Medicaid and major commercial payers for multi-specialty or surgical clients, and with Veradigm practice management products.
• 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.

Benefits

• Veradigm believes in empowering our associates with the tools and flexibility to bring the best version of themselves to work.
• Through our generous benefits package with an emphasis on work/life balance, we give our employees the opportunity to allow their careers to flourish.
• Quarterly Company-Wide Recharge Days Peer-based incentive “Cheer” awards
• Tuition Reimbursement Program To know more about the benefits and culture at Veradigm, please visit the links mentioned below: - https://veradigm.com/about-veradigm/careers/benefits/ https://veradigm.com/about-veradigm/careers/culture/ #LI-SL1 Veradigm is proud to be an equal opportunity workplace dedicated to pursuing and hiring a diverse and inclusive workforce.
• Thank you for reviewing this opportunity!
• Does this look like a great match for your skill set?