Medical Claims Auditor

Job Description

Job Title: Medical Claims Auditor – US Healthcare (TPA) Location: Malad West, Mumbai. Department: Claims / Quality Assurance Job Overview: We are seeking a detail-oriented and experienced Medical Claims Auditor to join our team. In this role, you will be responsible for conducting audits on medical claims to ensure accuracy, compliance with plan provisions, and adherence to federal and state regulations. Your expertise will help maintain quality assurance within the claims process, reduce errors, and support the financial integrity of our TPA operations. Key Responsibilities: ● Perform pre-payment and concurrent audits on medical claims for self-funded and level-funded health plans. ● Verify claims for accuracy in coding (ICD-10, CPT, HCPCS) for the application of plan benefits. ● Review plan documents alongside claim codes to determine the proper benefit assignments. ● Collaborate with claims examiners, supervisors, and compliance teams to resolve discrepancies. ● Document audit findings, prepare detailed reports, and present outcomes to internal stakeholders. ● Ensure claims adhere to regulatory guidelines including HIPAA, ERISA, and other applicable federal/state requirements. ● Participate in internal quality assurance initiatives and continuous improvement efforts. ● Maintain confidentiality of sensitive member and provider information. Required Qualifications: ● 3 years of experience in medical claims auditing, preferably in a US healthcare TPA or insurance environment. ● Strong knowledge of medical terminology, coding systems (ICD-10, CPT, HCPCS) , and claims forms ( CMS-1500, UB-04 ). ● Familiarity with healthcare regulations including HIPAA, ERISA, and ACA. ● Proficiency in auditing tools, claim systems, and Microsoft Office Suite. ● Certifications such as CPC, CPMA, or CCS are mandatory. ● Excellent analytical, organizational, and communication skills. Preferred Tools/Systems Experience: ● Claims adjudication platforms such as Trizetto, VBA, Plexis. ● EMR/EHR platforms and audit management systems. Job Type: Full-time Pay: ₹400,000.00 - ₹900,000.00 per year Benefits: Health insurance Leave encashment Paid sick time Paid time off Provident Fund Schedule: Fixed shift Monday to Friday Night shift US shift Education: Bachelor's (Required) Experience: Medical Claims Auditor: 3 years (Required) Language: English (Required) License/Certification: CPC Certification (Required) Location: Mumbai Suburban, Maharashtra (Required) Shift availability: Night Shift (Required) Work Location: In person