Outpatient Auditor III – Certified

🕒 May 19

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EXL

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10,000+ employees

💰 $2M Venture Round on 2015-01

Choosing a digital partner is about more than capabilities — it’s about collaboration and character.

📋 Description

• Apply in‑depth knowledge of CPT/HCPCS coding, APC payment methodologies, and outpatient regulatory guidelines to audit UB‑04 facility claims only, ensuring accurate APC assignment, proper packaging, and compliant facility billing. • Perform detailed hospital outpatient facility audits with a strong focus on APC assignment, payment status indicators, revenue code alignment, and OPPS reimbursement logic. • Review outpatient claims to validate correct CPT/HCPCS-to-APC mapping, including appropriate assignment of: • – Significant procedure APCs vs. packaged services • – Comprehensive APCs (C-APCs) • – Composite APCs where applicable • Audit UB‑04 facility claims to ensure accurate reporting of CPT/HCPCS codes, modifiers, revenue codes, and charge structures that directly impact APC payment. • Conduct audits across infusion therapy, outpatient surgeries, imaging, and interventional radiology, such as: • – Verifying correct APC assignment for chemotherapy and non-chemotherapy infusions, hydration services, and observation-related services • – Reviewing outpatient surgical encounters to ensure correct APC selection based on procedure complexity and status indicators • – Auditing interventional radiology encounters to confirm appropriate APC grouping and compliance with bundling rules.

🎯 Requirements

• Active credential(s) such as: • o CCS • o RHIA • o RHIT • o CPC (Multiple credentials strongly preferred) • Minimum 3 years of hospital outpatient facility coding and/or auditing experience, with direct exposure to APC-driven reimbursement. • Demonstrated expertise in: • – APC payment methodologies • – OPPS reimbursement logic • – CPT/HCPCS coding impact on APC assignment • – UB‑04 facility billing requirements • Hands-on experience auditing infusion services, outpatient surgeries, and interventional radiology, including APC packaging and bundling scenarios. • Strong understanding of payer contracts, claim adjudication, and reimbursement variance analysis. • **Preferred** • Advanced experience auditing complex APC encounters, including comprehensive and composite APC scenarios. • In-depth knowledge of infusion and injection coding, including drug status indicators and packaged vs. paid drugs. • Experience identifying retrospective overpayments tied to APC misassignment or improper unbundling. • Proficiency with 3M, Webstrat, Optum Encoder, or similar tools. • Ability to work independently in a high-volume remote audit environment. • Strong written, verbal, and analytical communication skills, especially in explaining APC payment logic. • Proficiency in Microsoft Excel, Word, OneNote, and related applications.

🏖️ Benefits

• Up to 10% annual travel (for team meetings and limited client onsite engagements.) • Collaborative environment: Work with experienced outpatient and APC-focused auditors. • Ongoing professional development: Stay ahead of APC and OPPS regulatory changes. • Mentorship & career growth: Learn from senior auditors and advance your outpatient auditing career. • Work-life balance: Enjoy remote flexibility with limited travel.