Medical Auditor

9371762436

About the Role

We are seeking a medically qualified professional to conduct desktop audits of health insurance claims (cashless and reimbursement), analyze provider (hospital) behavior and trends, and generate technical medical triggers to guide Provider Management and Claims teams. The role blends clinical judgment with data-driven analysis to strengthen fraud/waste/abuse (FWA) detection, ensure medical necessity, and optimize claim outcomes.

Key Responsibilities

• Conduct comprehensive desktop audits of cashless and reimbursement claims for medical necessity, appropriateness of care, coding accuracy, and tariff adherence.
• Validate clinical documentation (diagnosis, investigations, procedures, discharge summaries) against protocols and internal guidelines.
• Identify upcoding, unbundling, unnecessary investigations/procedures, and deviations from established pathways.
• Perform continuous trend analyses of hospital/provider patterns (LOS, admission rates, high-cost items, specialties, DRGs, package utilization).
• Develop and maintain risk scores/trigger lists for providers, departments, and procedure bundles.
• Generate early warning signals and pre-authorization medical triggers for impending cashless cases.
• Partner with Provider Management to recommend tariff negotiations, inclusion/exclusion of packages, and corrective action plans.
• Support Claims/Pre-auth teams with clinical clarifications, medical triggers, and defensible recommendations.
• Create audit summaries, dashboards, and case studies for leadership review and governance forums.
• Ensure compliance with company policies, regulatory standards, and clinical guidelines.
• Contribute to SOP updates, audit checklists, and continuous improvement initiatives.
• Conduct periodic provider audits (remote/desktop; occasional onsite if required) and support special investigations.

Qualifications

• Medical degree: BHMS / BAMS / BUMS (must-have).
• Strong analytical bend of mind; comfort with desktop audits and document-heavy review.
• Hospital Management or any relevant post-graduation is a plus (e.g., MHA, MPH, MBA in Healthcare).
• Proficiency in Microsoft Excel (lookups, pivots, conditional logic, data cleaning); familiarity with basic dashboards.
• 2-3 years of experience in health claims audit, provider analytics, utilization review, clinical coding, or medical quality in insurance/TPA/hospital setting preferred.

Desired Skills & Competencies

• Sound clinical reasoning; ability to assess medical necessity and evidence-based care.
• Working knowledge of tariffs, packages, DRGs, ICD/CPT, and hospital billing practices (added advantage).
• Analytical thinking: trend analysis, root-cause identification, pattern recognition.
• Strong written and verbal communication; ability to present findings succinctly.
• High integrity, confidentiality, and attention to detail.
• Collaboration mindset with Provider Management, Claims, and SIU/Fraud teams.

Tools & Technologies

• MS Excel (advanced functions, pivot tables, data validation).
• MS PowerPoint & Word for reporting and presentations.
• Exposure to claims processing systems, EMR/EHR, and basic BI tools (Power BI/Tableau) is a plus.

Key Performance Indicators (KPIs)

• Audit throughput & accuracy (cases audited, error detection rate).
• Financial impact (recoveries/savings, denial prevention, leakage reduction).
• Trigger effectiveness (hit rate of medical triggers, pre-auth decision quality).
• Provider corrective actions (closure of audit findings, reduction in repeat issues).
• Turnaround time and documentation quality (audit reports, dashboards).