Job Description

Core Responsibilities

• Execute quality audits and control activities for claims processing.
• Support the implementation of automated audit tools to improve efficiency and accuracy.
• Assist in fraud detection and prevention efforts to protect financial integrity.
• Track and report on key performance indicators (KPIs) related to claims accuracy, error rates, and audit outcomes.
• Follow standardized review processes to ensure consistency in claims quality assessments.
• Coordinate with the claims team to address discrepancies and support quality improvements.
• Ensure compliance with medical coding, billing regulations, and internal policies.
• Contribute to fostering a culture of quality assurance and continuous improvement.
• Prepare and share audit findings and insights with senior team members to support decisions.
• Help enhance claims quality assessment methods by applying best practices.
• Maintain accurate documentation of audit procedures and results.
• Support risk management by identifying potential issues in claims processing.

Quality & Excellence Management

• Monitor claims processing trends to help identify areas for quality improvement.
• Assist in enhancing compliance monitoring processes.
• Support initiatives aimed at reducing claims errors and improving efficiency.
• Apply audit control best practices to help achieve operational excellence.
• Provide input on technological solutions that may improve auditing processes.
• Promote high standards in audit and control work.

Preferred Educational Qualifications and Professional Certifications

• Bachelor’s degree in Medicine (mandatory)
• Professional certifications such as CPCU, AICPCU, CHC, LOMA certifications, or equivalent are an advantage.

Experience

• 3–5 years of experience in healthcare insurance claims audit and controls.
• Previous exposure to quality audits, compliance processes, and claims processing is preferred.