- Review and audit medical claims against patient medical records to ensure accuracy and completeness of documentation.
- Identify discrepancies between clinical documentation and billed services, highlighting variances and potential billing errors.
- Perform detailed clinical reviews to validate diagnosis, procedures, and level of care in accordance with industry standards.
- Ensure compliance with CMS guidelines, payer policies, and regulatory requirements during claim review processes.
- Conduct best practice audits to identify documentation gaps, coding inaccuracies, and revenue leakage opportunities.
- Provide structured findings and audit reports with clear recommendations for corrective action and process improvement.
- Collaborate with coding, billing, and provider teams to resolve audit findings and support accurate claim submissions.
- Monitor trends in audit results and identify recurring issues requiring targeted education or intervention.
- Support quality assurance initiatives by maintaining audit accuracy benchmarks and meeting productivity standards.
- Participate in continuous improvement activities, including updates on CMS regulations, clinical guidelines, and payer policy changes.
- Familiarity with basic medical terminology and concepts used in care management.
- Ability to effectively participate in a multi-disciplinary team including internal and external participants.
- Should have a good understanding of US healthcare system and management.
- Perform audit based on clinical knowledge while reviewing the medical record
- Demonstrate learning skills during process training and in advancing career
- Perform quality assurance reviews to assess comprehension of training efforts.
- Ensure to process the audit with accountability
- Ensure to view all documented system information as well as any additional records/data presented to support a determination or recommendation.
- Condenses all clinical information into a clear and precise clinical picture while taking a final decision.
- Pro-actively and consistently engage in enhancing process/work knowledge and delivery the work with high values.
- Actively update process knowledge and follow the new change in process.
- Be ready to analyze the errors and if required approach to quality team for further clarification.
- Maintain a professional work environment.
- Follow every aspect of SOP without fail.
- Complete received Audits with Quality.
- Achieve expected Quality and production target.
- Follow project-related protocols and instructions.
- Update all the logs like productivity, Clarification log, and any other logs applicable daily.
- Complete alignment with Manager /TL in terms of program delivery.
- Responding to all emails promptly without fail.
- Ensure compliance of the entire team.
- Qualifications:
- Bachelor’s degree in nursing
- Active State Nursing certification is Mandatory
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Minimum 3 years of clinical/hospital experience is mandatory
- Experience:
- Minimum 3 years of clinical experience.
- Auditing experience (Optional)
- Communication:
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Strong written (documentation) and oral communication skills
- Working Hours:
- 40 hours per week as Full-time employee
- Shift time: 08:00 AM TO 05:00 PM IST (It might be changed based on project requirements)
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Weekends: Off
- Telecommuter/Internet requirements, if applicable:
- High Speed internet connection at home, must be broadband
- Must understand and adhere with telecommuter policy
Skills Required
- Bachelor's degree in nursing
- Active state nursing certification
- Minimum 3 years of clinical or hospital experience
- Strong written and oral communication skills
- Auditing experience
- High-speed broadband internet connection for telecommuting
- Ability to understand and adhere to the telecommuter policy
What We Do
Choosing a digital partner is about more than capabilities — it’s about collaboration and character. Unrealistic overhauls and off-the-shelf products ignore what matters most — your unique needs, culture, goals, and your legacy data and technology environments. At EXL, our collaboration is built on ongoing listening and learning to adapt our methodologies. We’re your business evolution partner—tailoring solutions that make the most of data to make better business decisions and drive more intelligence into your increasingly digital operations. Whether your goals are scaling the use of AI and digital, redesign operating models, or driving better and faster decisions, we’re here to partner with you to help you gain—and maintain—competitive advantage with efficient, sustainable models at scale. Our expertise in transformation, data science, and change management helps make your business more efficient and effective, improve customer relationships and enhance revenue growth. Instead of focusing on multi-year, resource- and time-intensive platform designs or migrations, we look deeper at your entire value chain to integrate strategies with impact. We use our specialization in analytics, digital interventions, and operations management—alongside deep industry expertise — to deliver solutions that help you outperform the competition. At EXL, it’s all about outcomes—your outcomes—and delivering success on your terms. Share your goals with us and together, we’ll optimize how you leverage data to drive your business forward. For more information, visit www.exlservice.com.
