Medical Billing Auditor

JOB DESCRIPTION

I. JOB DETAILS

Job Title

Medical Billing Auditor

Reporting Supervisor

Head- Accounts & Finance

II. JOB PURPOSE 

Ensure the accuracy and integrity of medical billing processes. The focuses on identifying and preventing billing discrepancies, errors, and potential revenue loss. By thoroughly reviewing and verifying medical claims, the auditor helps safeguard against inaccuracies and ensures compliance with industry standards, ultimately promoting efficiency and preventing financial leakages.

III. KEY RESPONSIBILITIES 

Core Responsibilities

• Ability to thoroughly review and compare patient files, medical records, and billing data to identify discrepancies. for all planned discharges and high value/ALOS/ICU patients.
• Ability to analyze data and track trends in deductions, billing errors, or overbilling issues.
• Ensuring updating of billing specially credit billing on daily basis
• Control deductions that arise due to incorrect billing or overbilling
•  Review medical records and compare them with the billing to ensure that all charges are accurate and reflective of the care provided.
• Ensure that accurate billing practices are followed to prevent the same errors from occurring in the future.
• Monitoring of all order items to ensure no under or over charging happens
• Correlating Medical records and patients billing to ensure billing is in sync with the medical treatment.
• Coordinating with MRD/Nursing/Medical Team/TPA to ensure credit bills are dispatched in accordance with the MOUs/Agreements with TPAs/Corp/PSU clients
• Ensuring real time monitoring of deductions. maintaining a proper tracker having relevant reasons of such deductions and follow-up with concerned stakeholders ( IPD billing, medical/Ops teams/collections/TPA cells/MRD for quick resolution of such deductions.
• Deductions arising due to incorrect billing, over billing etc.. to be controlled to ensure accurate billing for such cases in future to avoid repetitive similar deductions

IV. KEY PERFORMANCE INDICATORS

Measurable Deliverables 

• Achieving a minimum accuracy rate of 98% or higher in reviewing and processing medical claims.
• Identifying and rectifying billing errors, discrepancies, or discrepancies with a defined error detection rate (e.g., identifying and correcting 95% of billing inaccuracies).
• Ensuring that audits are completed within the established timelines,
• Ensuring compliance with industry regulations, payer policies, and internal standards, maintaining a 100% adherence rate to all applicable rules and guidelines.
• Timely and accurate submission of audit reports, tracking all identified issues, corrective actions, and outcomes within an established reporting period.
• Achieving a certain satisfaction score from internal or external stakeholders based on communication and resolution of billing issues.

V. JOB REQUIREMENTS

Minimum Qualifications

BDS + MHA/ MBA

Experience

Fresher or Minimum 1 year experience .

Technical Skills

• Computer Literacy, with expertise in Excel and Power Point.
• Knowledge of other statistical software tools.
• Analytical bent of mind.
• Quality Management in Healthcare.
• Service Excellence.

 Knowledge Skills

• Knowledge of Consumables and Drugs
• Knowledge about NABH standard, ISO standard, JCI, Auditing skills, Analytical skills
• Proficient in MS office

Language Skills

English & Hindi

VI. KEY INTERACTIONS 

Key Internal Contacts

Key External Contacts

• · Unit Head – Hospital Operations 
• · M.S. and team
• · Operations Head and team 
• · Support Services Head and team
• · Nursing Head and team
• · Clinicians 
• · Patient Experience

• Patients / patient’s attendants