The Medical Audit detects any inconsistencies that could negatively impact healthcare processes. Will have direct interaction with external and internal stakeholders and will need to become knowledgeable of policy benefits, ICD/CPT codes to properly evaluate cases. The person will work under the supervision and guidance of the Medical Audit Lead.

Responsibilities:

• Review and evaluate complex medical claims, including medical records, diagnostic reports, preventive procedures, medical images, and resource utilization.
• Monitor hospitalized cases and review medical records
• Ensure compliance with contracts, both for the member and for healthcare providers
• Re-validate the coverage of hospitalized patients (review if the coverage is in accordance with the plan, if it is not a pre-existing condition, maternity amounts, if their admission is not associated with exclusions or limitations of the policy)
• Record patient information in the designated tool (spirit)
• Review aspects related to medical relevance, i.e., Evidence-Based Audit (evidence-based practice is defined as the conscious, explicit, and judicious use of the best available scientific evidence in making decisions about the care of individual patients)
• Identify deviations in the audit process and contact the hospital provider
• Comply with audits of hospital credit invoices sent by the claims department according to evaluation criteria
• Identification and Notification of Cost Variation in Providers
• Notification of Adverse Events in Provider
• Participate in periodic quality committees with the provider and medical audit; under the supervision of his head.
• Analyze the account statement of that benefit and identify how the cost is divided: in the event that the greatest weight is given to supplies or medicine, verify that their values are within the market; In the same way, it must be ensured that what is billed has been administered or performed on the patient
• Identify savings opportunities, through the analysis of the cases that the insurer finances; This analysis will be carried out on the pathologies that have the greatest impact on hospital costs, either due to patient frequency or the cost of the disease
• Identify discrepancies or inconsistencies in medical documentation and request additional information from healthcare providers when necessary.
• Communicate with healthcare providers and clients to obtain additional information and clarify any questions related to claims.
• Stay up-to-date on regulations and best practices in the field of medical auditing.
• Contribute to the development and implementation of medical audit processes and procedures.

• Participate in training and professional development activities.

• Medical Doctor or Medical Auditor Degree Preferred.

• Minimum of 3 years of experience in medical auditing.
• Strong knowledge of the healthcare billing process.
• Exceptional analytical and problem-solving skills.
• Excellent oral and written communication skills in both Spanish and good in English. (fluency is a plus, English level that allows for reading medical records in English and effective communication with English-speaking healthcare providers and clients).
• Ability to work independently and as part of a team.
• Detail-oriented and committed to accuracy.
• Proficient in MS Office Suite (Word, Excel, Email) and other relevant computer programs.
• Excellent organizational skills with a strong attention to detail.
• Ability to prioritize tasks, manage time effectively, and meet deadlines.
• Customer-focused with a commitment to providing exceptional service.
• Ability to work effectively in a fast-paced, high-volume environment.
• Ability to maintain confidentiality and discretion when handling sensitive member information.