Outpatient Auditor III

🔥 14 hours ago

🇺🇸 United States – Remote

💵 $70k - $90k / year

⏰ Full Time

🟡 Mid-level

🟠 Senior

🔎 Auditor

👻 Ghost score 1%

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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

• Perform detailed hospital outpatient facility audits focused on APC assignment, payment status indicators, revenue code alignment, and OPPS reimbursement logic • Review claims to validate CPT/HCPCS-to-APC mapping, including significant procedure, packaged, comprehensive, and composite APCs • Audit UB-04 facility claims for accurate CPT/HCPCS codes, modifiers, revenue codes, and charge structures • Evaluate APC packaging rules for ancillary services, supplies, minor procedures, and drug administration services • Audit infusion therapy, outpatient surgeries, imaging, and interventional radiology encounters • Verify APC assignment for chemotherapy and non-chemotherapy infusions, hydration, and observation services • Review surgical encounters for APC selection based on procedure complexity and status indicators • Audit interventional radiology encounters for appropriate APC grouping and bundling compliance • Validate billing of technical components including nursing services, equipment, supplies, imaging contrast, and facility resources • Evaluate facility billing separately from professional claims • Apply CMS OPPS regulations, CPT rules, NCCI edits, and AHA Coding Clinic guidance • Identify overpayments, underpayments, misassigned APCs, inappropriate unbundling, and missed reimbursement opportunities • Use 3M, Webstrat, Optum Encoder, and EXL proprietary systems to analyze APC payment outcomes • Produce clear, defensible audit findings describing reimbursement impacts and compliance risks • Stay current on APC updates, OPPS rule changes, CMS transmittals, and payment indicator revisions • Meet or exceed EXL productivity, quality, and compliance standards

🎯 Requirements

• Active credential such as CCS, RHIA, RHIT, or CPC • Minimum 3 years of hospital outpatient facility coding and/or auditing experience with direct exposure to APC-driven reimbursement • Expertise in APC payment methodologies • Expertise in OPPS reimbursement logic • Knowledge of CPT/HCPCS coding impact on APC assignment • Knowledge of 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 • Advanced APC auditing experience, including comprehensive and composite APC scenarios preferred • Knowledge of infusion and injection coding, drug status indicators, and packaged versus paid drugs preferred • Experience identifying retrospective overpayments tied to APC misassignment or improper unbundling preferred • Proficiency with 3M, Webstrat, Optum Encoder, or similar tools preferred • Ability to work independently in a high-volume remote audit environment preferred • Strong written, verbal, and analytical communication skills preferred • Proficiency in Microsoft Excel, Word, OneNote, and related applications preferred

🏖️ Benefits

• Remote work from home with limited travel • Up to 10% annual travel for team meetings and limited client onsite engagements • Collaborative environment with experienced outpatient and APC-focused auditors • Ongoing professional development on APC and OPPS regulatory changes • Mentorship and career growth opportunities • Work-life balance • Base salary range of $70,000–$90,000, with potential compensation above the range in higher-cost zones