Medical Claims Auditor

Overview

Main Task, Duties, Responsibilities & Accountabilities**

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• Conduct **data-driven, on-site audits** of healthcare providers to thoroughly examine medical records and supporting documentation, ensuring accuracy of claimed services and compliance with regulatory and contractual obligations.
• Perform **in-depth investigative audits** of suspected fraud, misuse or abuse by healthcare providers or clinicians. Collect and analyze relevant documentation and evidence to support findings and further evaluation.
• Prepare and submit **comprehensive audit reports** within the required turnaround time following on-site investigations. Ensure reports include clear findings, references, and are shared with healthcare providers for claim-specific review, response, and confirmation.
• Maintain accurate and organized **audit documentation**, including reports, communication trails, and evidence, in designated shared folders for tracking, accountability, and future reference.
• **Manage follow-up and resolution** of disputed audit findings. Coordinate meetings with providers to address disagreements; escalate unresolved or contentious cases to senior management and regulatory authorities as appropriate.
• **Review patient medical records** and clinical documentation to assess claim appropriateness and ensure compliance with standardized coding systems such as ICD, CPT, HCPCS, DDC, and CDT, and in accordance with agreed-upon tariffs.
• Evaluate **Explanation of Benefits (EOB)** statements and challenge inappropriately paid or denied claim items based on audit findings and policy alignment.
• Ensure the **timely submission** of audit outcomes, including identification of non-compliant providers or practices, to department managers. Bottom of Form
• Support the preparation and submission of required reports to regulatory authorities.
• **Experience:** Minimum 5 years of experience in healthcare provider Audit from major TPA or Insurance companies in UAE