Job Description Summary:
The RCM Quality Auditor is a critical member of the Revenue Cycle Management quality assurance function, responsible for auditing end-to-end RCM processes including medical coding, claims billing, accounts receivable follow-up, denial management, and payment posting.
This role ensures that all transactions meet required accuracy benchmarks, comply with HIPAA regulations, payer guidelines, and client-specific SOPs. The Quality Auditor serves as the operational backbone of quality governance — identifying defects, performing root cause analyses, supporting corrective actions, and continuously contributing to a culture of excellence across the revenue cycle.
WHAT YOU’LL DO
Quality Auditing
- Audit daily transactions across assigned RCM verticals ( billing, AR, denials, posting) against defined quality parameters
- Perform end-to-end internal audits covering pre-bill, post-bill, and post-payment stages of the revenue cycle
- Validate ICD-10, CPT, and HCPCS codes for accuracy, specificity, and payer-specific compliance rules
- Review claim scrubbing outputs to identify errors prior to submission and flag for correction
- Ensure audit sample size meets the defined monthly audit plan (100% coverage target)
Process Compliance
- Ensure strict adherence to client-specific SOPs, payer guidelines, HIPAA, PHI, and CMS regulations
- Monitor and flag critical compliance errors with zero-tolerance — escalate immediately to Quality Team Leader
- Verify that all claim edits, modifier usage, and medical necessity documentation align with payer contracts
- Support internal compliance audits and provide documentation for regulatory or client reviews
Error Analysis & Root Cause Analysis (RCA)
- Classify errors into defined categories: critical, non-critical, process, and knowledge-based
- Conduct root cause analysis for recurring error patterns and document findings systematically
- Prepare error trend analysis reports on a weekly and monthly basis to highlight systemic issues
- Track corrective action plan (CAP) implementation and verify effectiveness post-correction
Training & Coaching
- Identify skill gaps from audit data and conduct targeted one-on-one feedback sessions
- Support the Quality Team Leader in designing and delivering refresher training programs
- Conduct calibration sessions with operations staff to align understanding of quality standards
- Create and maintain error-specific reference guides and job aids for operations teams
Reporting & Documentation
- Prepare and submit daily, weekly, and monthly quality MIS reports, dashboards, and scorecards
- Maintain up-to-date audit logs, error trackers, feedback sheets, and calibration records
- Document all audit findings with evidence and maintain an organized, audit-ready file system
- Generate RCA reports, corrective action logs, and quality trend charts for leadership review
Process Improvement
- Participate in Lean, Six Sigma, and automation-driven improvement initiatives across RCM
- Identify manual and repetitive quality tasks that can be streamlined through automation or technology
- Collaborate with IT and operations teams to pilot quality improvement technologies (e.g., AI auditing tools)
- Benchmark internal quality standards against industry leaders and recommend improvements
Client /Stake holder Interaction
- Prepare quality summary reports, audit findings, and action plans for client quality calls
- Assist in responding to client quality queries with data-backed responses and corrective timelines
- Maintain client-facing quality scorecards and ensure timely submission per contractual timelines
Education & Experience
- Bachelor’s degree in any discipline; Healthcare Management or Life Sciences preferred
- 5 years of experience in RCM quality auditing (payment, Billing, AR, Denials patient calling)
- BPO / KPO healthcare background is a plus
Certifications
- Six sigma certification preferrable
- Certification required within 12 months of joining if not already held
- CPC, CRC, CPMA, CCS, RHIT, or equivalent coding/billing certification preferrable
Technical Skills
- Proficiency in ICD-10-CM, CPT, HCPCS Level II; familiarity with NCCI edits and LCD/NCD guidelines
- Working knowledge of Medicare, Medicaid, and commercial payer billing and audit guidelines
- Strong understanding of HIPAA, PHI, CMS regulations, and patient data privacy requirements
- Experience with EMR/PMS systems proficiency in MS Excel and QA dashboards
Soft Skills
- Strong analytical thinking and exceptional attention to detail
- Excellent verbal and written communication skills
- Effective feedback delivery and coaching abilities
- Knowledge of denial trends, AR aging, and revenue recovery processes is a strong advantage
Compensation for this job is subject to market conditions, geographic considerations, the candidate’s unique skills and experience, state and local laws, and budget. Our commitment to pay transparency is a testament to our dedication to creating a fair, equitable, and inclusive workplace. By continuously analyzing market trends, staying abreast of changes in state laws, and making budgetary adjustments accordingly, we strive to ensure that our compensation practices reflect the value we place on our associates’ unique contributions and support their professional growth.
Enhancing Lives and Building Careers
Veradigm believes in empowering our associates with the tools and flexibility to bring the best version of themselves to work and to further their professional development. Together, we are In the Network. Interested in learning more?
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Visa Sponsorship is not offered for this position.
At Veradigm, our greatest strength comes from bringing together talented people with diverse perspectives to support the needs of healthcare providers, life science companies, health plans, and the patients they serve. The Veradigm Network is a dynamic, open community of solutions, external partners, and cutting-edge artificial intelligence technologies that provide advanced insights, technology, and data-driven solutions. Veradigm offers a comprehensive compensation and benefits package, including holidays, vacation, medical, dental, and vision insurance, company paid life insurance and retirement savings.
Veradigm’s policy is to provide equal employment opportunity and affirmative action in all of its employment practices without regard to race, color, religion, sex, national origin, ancestry, marital status, protected veteran status, age, individuals with disabilities, sexual orientation or gender identity or expression or any other legally protected category. Applicants for North American based positions with Veradigm must be legally authorized to work in the United States or Canada. Verification of employment eligibility will be required as a condition of hire. Veradigm is proud to be an equal opportunity workplace dedicated to pursuing and hiring a diverse and inclusive workforce.
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