Clinical Readmission Review Auditor III

🕒 September 2

🇺🇸 United States – Remote

💵 $70k - $98.7k / year

⏰ Full Time

🟡 Mid-level

🟠 Senior

🔎 Auditor

👻 Ghost score 22%

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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 readmission likelihood • Evaluate medical necessity and clinical appropriateness of inpatient services using applicable 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, well-supported clinical findings and rationale for determinations • Respond to provider disputes or appeals through objective clinical reassessment supported by medical-record evidence • Meet EXL quality, productivity, timeliness, and documentation standards • Maintain current knowledge of readmission review practices, clinical guidelines, utilization management principles, and regulatory or client 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 • Experience in inpatient case management, utilization review, clinical auditing, quality, or readmission review is preferred • 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 • Self-motivated and able to work independently in a remote setting while meeting quality and productivity expectations • Bachelor of Science in Nursing (BSN) is preferred

🏖️ Benefits

• Benefits information provided at https://www.exlservice.com/us-careers-and-benefits • Fully remote work-from-home arrangement • Up to 10% annual travel for team meetings or limited client engagements