EXL—Senior Executive - Claims Audit

Job description

Description: Job description: - Review and analyze medical records and claims data to ensure accuracy, completeness, and compliance with healthcare regulations and payer requirements. - Verify that all necessary clinical documentation is included to support claim submissions and medical necessity. - Identify and resolve inconsistencies, errors, or missing documentation in patient records or claims. - Prioritize and manage workloads to ensure expedited and high-priority cases are processed within defined timelines. - Collaborate with healthcare providers, coders, and billing staff to obtain or clarify necessary information. - Ensure compliance with HIPAA, CMS, and other regulatory guidelines related to medical record handling and claims processing. - Prepare accurate reports and summaries of claim findings, trends, and potential process improvements. - Support internal audits and quality assurance initiatives by providing detailed documentation and analytical insights. - Maintain a strong understanding of healthcare terminology, coding standards (ICD, CPT, HCPCS), and insurance claim procedures.