Quality Auditor

Firstsource • Louisville, KY, United States • 2d ago

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 Third-Party Liability (TPL) processes to ensure accuracy, compliance, and optimal reimbursement.

Key Responsibilities

Perform 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-related denials
Review and validate clinical denials such as:
- Medical necessity
- Diagnosis-procedure linkage
- Level of care
- Non-covered services
- Documentation-related 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-related 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 (Healthcare/RCM preferred)
Certifications preferred: AAPC (CPC/COC) / AHIMA

Experience

5+ years of experience in Revenue 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. All qualified applicants are considered for employment without regard to race, color, age, religion, sex, sexual orientation, gender identity, national origin, disability, protected veteran status, or any other characteristic protected by federal, state or local law.

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