RCM Quality Auditor

The RCM Quality Auditor - AR & Denials evaluates the AR follow-up, denial, and rejection work completed by our Revenue Cycle Services teams. This role identifies errors early—before they cost our clients money or create compliance risk. You will score completed work in a fair and consistent manner, clearly explain what went wrong and why, and partner with teams to correct the underlying issue so it does not recur.

Qualifications

• 2 to 4 years of US healthcare revenue cycle experience in AR follow-up, denial management or AR QA.
• Strong working knowledge of CARC/RARC codes, payer appeal processes, timely filing limits, and payer portal and IVR follow-up.
• Familiarity with clearinghouse rejections, scrubber edits and common front-end denial causes (eligibility, authorization, registration).
• Strong Excel skills and clear written English for feedback and client-facing summaries.
• Preferred: experience with Medicare, Medicaid and major commercial payers for multi-specialty or surgical clients, and with Veradigm practice management products.

Audit the work

• Audit plan. Conduct audits based on the approved monthly plan, including random samples, targeted samples (high-dollar accounts, complex specialties, new payers and new clients), and 100% audits for new joiners or associates on a performance improvement plan.
• Source checks. Review each audited account against claim history, ERAs/EOBs, payer portal and call records, and payer correspondence.
• Follow-up quality. Ensure follow-up actions are accurate, properly documented, and completed on time; confirm that account notes are clear enough for the next person to take action; and verify that next-action dates are set appropriately.
• Denials and appeals. Verify that denials are routed to the correct work queue, that corrective actions align with the denial reason, and that appeals and reconsiderations satisfy payer requirements and filing limits.
• Rejections and edits. Examine clearinghouse rejections and scrubber edits, confirming fixes were applied correctly and within required timelines.
• Gaps and leakage. Identify incorrect write-offs and adjustments, missed timely filing or appeal deadlines, unworked underpayments, and accounts closed without resolution.

Find the root cause and fix it

• Root cause analysis. Investigate repeat or high-impact errors, determine the root cause, and help develop and monitor corrective actions (CAPA), such as retraining, SOP updates, and checklist changes. Then confirm that the implemented fix resolved the issue.
• Training support. Identify skill gaps from audit results, recommend refresher training, assist with onboarding new joiners, and ensure job aids and payer reference guides remain current.
• Trends. Provide payer-level insights, including denial spikes, recoupments, and preventable front-end denials, to operations, AR and Denial Management leadership.

Report, escalate and stay compliant

• Reporting. Deliver daily, weekly, and monthly quality reports and scorecards at the associate, team, and client level, including RCA reports and trend charts for leadership.
• Escalation. Escalate critical errors immediately, with special focus on issues that affect revenue, compliance, or timely filing.
• Staying current. Monitor payer policy changes, appeal and timely filing rules, and annual code updates; flag required changes to SOPs and payer rule references.

Help improve the process

• Automation. Identify repetitive QA activities that may be suitable for automation, and participate in Lean, Six Sigma, and AI-assisted audit pilots.
• Transitions. Assist with new client transitions, process documentation, and knowledge assessments.