Medical File Auditor – TPA Claim Process

Job Title: Medical File Auditor – TPA Claim Process

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Experience Required:

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Job Summary

The Medical File Auditor is responsible for reviewing, verifying, and auditing medical claim files submitted by hospitals under cashless and reimbursement processes. The role ensures accuracy, compliance with policy guidelines, proper billing, and prevention of financial leakage.

Key Responsibilities

• Review and audit medical claims, patient files, discharge summaries, bills, and supporting documents.
• Verify medical treatments, diagnosis codes, procedures, and ensure alignment with policy terms and TPA guidelines.
• Identify discrepancies in billing, overcharging, bundling, or non-payable items.
• Assess claims for eligibility, coverage, and correctness before approval.
• Coordinate with hospitals, internal teams, and insurance companies for clarifications or missing documents.
• Ensure adherence to claim processing SOPs and regulatory standards.
• Prepare audit notes, approval recommendations, and summary reports.
• Support the claims team in decision-making for claim approvals or rejections.
• Maintain accurate records and update claim data in the TPA system.
• Assist in continuous improvement of claim auditing processes.

Key Skills Required

• Strong knowledge of medical terminology, treatments, and hospital billing.
• Understanding of TPA claim processes (cashless & reimbursement).
• Good analytical and auditing skills.
• Attention to detail and accuracy.
• Effective communication and coordination abilities.
• Proficiency in MS Office and claim processing software.
• Ability to work under deadlines.

Qualifications

• Graduate in any field; preference for candidates with a

  Degree/Diploma in Nursing, Pharmacy, Medical Records, or Healthcare Management

  .
• Experience in TPA, hospital billing, medical coding, or claim processing is an added advantage.