Quality Auditor

firstsourc • Remo, VA

6d

About The Position

Responsible for auditing Hospital Billing (HB) and Professional Billing (PB) accounts with focus on technical and clinical denials, insurance follow-up workflows, Workers’ Compensation (WC), and Third-Party Liability (TPL) processes to ensure accuracy, compliance, and optimal reimbursement.

Requirements

• 5+ years of experience in Revenue Cycle Management (RCM)
• Strong exposure to both: Hospital Billing (HB), Professional Billing (PB)
• Experience in: Denials management (technical & clinical), Insurance follow-up, Appeals handling, WC and TPL workflows
• Strong understanding of payer guidelines and billing workflows
• Knowledge of CPT, ICD-10, modifiers, and denial workflows
• Analytical thinking and RCA capability
• Strong communication and stakeholder management skills
• Ability to identify process gaps and drive quality improvements

Nice To Haves

• Audit / QA activities preferred
• Experience with preferred

Responsibilities

• Perform end-to-end audits of HB and PB accounts including billing, denials, and AR follow-up activities
• Review and validate technical denials such as: Eligibility issues, Demographic errors, Duplicate claims, Timely filing denials, Authorization issues, Provider/NPI-related denials
• Review and validate clinical denials such as: Medical necessity, Diagnosis-procedure linkage, Level of care, Non-covered services, Documentation-related denials
• Audit insurance follow-up activities including: Claim status review, Denial handling, Appeals, Underpayment follow-up
• Review and evaluate WC and TPL claims including: Liability handling, Coordination of benefits, Documentation validation
• Validate coding-related denial scenarios involving CPT, ICD-10, modifiers, and payer edits
• Conduct root cause analysis (RCA) and identify denial/error trends
• Provide actionable feedback and coaching inputs to operations teams
• Ensure compliance with payer guidelines, CMS regulations, and client SOPs
• Participate in internal/client calibration sessions
• Maintain audit accuracy and productivity SLAs
• Execute random and targeted audits
• Ensure audit consistency and inter-rater reliability (IRR)
• Track defect trends, denial patterns, and recovery opportunities
• Support denial prevention and process improvement initiatives

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level