Clinical Readmission Review Auditor III

🔥 12 hours ago

🇺🇸 United States – Remote

💵 $70k - $98.7k / year

⏰ Full Time

🟡 Mid-level

🟠 Senior

🔎 Auditor

👻 Ghost score 1%

What it means: how likely this posting is sitting open without active hiring.How to read it: 60% or higher means we think this is a ghost. Lower scores are less of a worry.How we score it: age, reposts, open roles vs team size, how fast jobs close, and whether pay is listed.Fine print: an estimate from public data, not a judgment of the company. Real jobs can score high, so treat it as a hint, not a fact.

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EXL

WebsiteLinkedInAll Job Openings

10,000+ employees

🏥 Healthcare

🛡️ Insurance

📦 Logistics

💰 $2M Venture Round on 2015-01

Healthcare • Insurance • Logistics

EXL is a business consulting and services firm that focuses on leveraging data to enhance business operations and decision-making. With a strong emphasis on collaboration and adaptability, EXL partners with organizations to address their unique needs and culture while integrating data science and technology solutions. The company's areas of expertise include operations management, decision analytics, digital transformation, and various industries such as healthcare, finance, and insurance. EXL's mission is to help clients drive business evolution and maintain competitive advantage through tailored solutions and effective use of data.

📋 Description

• Conduct comprehensive clinical reviews of initial and subsequent inpatient admissions to evaluate the relationship between episodes of care • Review complete medical records, including clinical presentation, diagnoses, treatment, response to treatment, discharge disposition, follow-up plan, and subsequent readmission • Assess whether readmissions were clinically related to prior admissions and whether opportunities existed to prevent or reduce them • Evaluate medical necessity and clinical appropriateness of inpatient services using clinical criteria, client requirements, and evidence-based standards • Identify concerns involving discharge readiness, continuity of care, follow-up services, medication management, and other clinical factors • Prepare clear, concise, and well-supported clinical findings and rationale • Respond to provider disputes or appeals through objective clinical reassessment • Meet EXL quality, productivity, timeliness, and documentation standards • Maintain current knowledge of readmission review practices, clinical guidelines, utilization management principles, and applicable requirements • Protect confidential information and comply with HIPAA and EXL policies and procedures

🎯 Requirements

• Active, unrestricted Registered Nurse (RN) license in the United States is required • At least four years of acute-care clinical nursing experience • Strong knowledge of inpatient care, disease progression, discharge planning, transitions of care, medical necessity, and factors contributing to readmissions • Ability to synthesize complex medical-record documentation and make objective, evidence-based clinical determinations • Strong written and verbal communication skills • Proficiency with Microsoft Excel, Word, and OneNote • Strong overall computer literacy • Ability to work independently in a remote setting while meeting quality and productivity expectations • Compliance with HIPAA and EXL policies and procedures

🏖️ Benefits

• Fully remote work-from-home arrangement • Up to 10% annual travel for team meetings or limited client engagements • Benefits information provided at https://www.exlservice.com/us-careers-and-benefits • Base salary across a national hiring scale • Compensation may exceed the posted range in higher-cost zones such as California, New York, and New Jersey