Medical Auditor

Role & responsibilities

• Perform audit reviews of adjudicated health / hospital / medical claims to verify correctness, completeness, and adherence to policy guidelines, contractual terms, and regulatory norms.
  
• Use sampling and systematic review techniques (random audits, targeted audits, high-value claims audits) to ensure quality coverage across volumes.
  
• Check for proper documentation, coding (ICD / CPT / procedure / diagnosis codes), member eligibility, policy coverage, benefit limits, copayments, exclusions, etc.
  
• Validate whether preauthorization, referrals, or supporting documentation was appropriately obtained / processed.
  
• Identify and flag discrepancies, overpayments, underpayments, duplicate claims, billing errors, or noncompliance.
  
• Prepare detailed audit reports, error summaries, quality metrics (error rates, root cause, trend analysis) and share with claims operations / processing teams.
  
• Monitor and track corrective action plans; follow up to ensure error fixes, retraining, process changes.
  
• Provide feedback, coaching, or training inputs to claims processors / adjudicators based on audit findings.
  
• Collaborate with operations, compliance, medical review, provider relations, or fraud teams to resolve claim issues.
  
• Assist in updating or refining claims quality standards, guidelines, checklists, SOPs, and workflows.
  
• Support internal and external audits, regulatory inspections, and compliance reviews.
  
• Ensure confidentiality of sensitive claim and health data and follow data privacy / security rules.
  
• Participate in continuous process improvement initiatives (lean, Six Sigma, quality initiatives) to reduce error rates and increase efficiency.
  
• Maintain uptodate knowledge on health insurance regulations, industry standards, guidelines, and best practices.
  

Preferred candidate profile

BAMS, BHMS, MBBS