Clinical Readmission Review Auditor III

This is a fully remote position, open to applicants in United States.

📋 Description

• Perform thorough clinical evaluations of both initial and subsequent inpatient admissions to assess the connection between care episodes.

• Analyze comprehensive medical records, which encompass clinical presentation, diagnoses, treatment details, response to treatment, discharge plans, follow-up strategies, and any subsequent readmissions.

• Determine if readmissions are clinically linked to previous admissions and identify potential opportunities for prevention or reduction.

• Evaluate the medical necessity and clinical suitability of inpatient services by applying clinical criteria, client specifications, and evidence-based standards.

• Detect issues related to discharge readiness, continuity of care, follow-up services, medication management, and other clinical considerations.

• Generate clear, concise, and well-supported clinical findings along with rationales.

• Address provider disputes or appeals through impartial clinical reassessment.

• Adhere to EXL's quality, productivity, timeliness, and documentation standards.

• Stay updated on readmission review practices, clinical guidelines, utilization management principles, and relevant requirements.

• Safeguard confidential information and conform to HIPAA and EXL policies and procedures.

⛳️ Requirements

• A valid and unrestricted Registered Nurse (RN) license in the United States is mandatory.

• Minimum of four years of acute-care clinical nursing experience is required.

• In-depth understanding of inpatient care, disease progression, discharge planning, transitions of care, medical necessity, and factors influencing readmissions.

• Capability to analyze complex medical record documentation and make objective, evidence-based clinical assessments.

• Excellent written and verbal communication abilities.

• Proficiency in Microsoft Excel, Word, and OneNote.

• Strong overall computer skills.

• Ability to work autonomously in a remote environment while fulfilling quality and productivity expectations.

• Adherence to HIPAA and EXL policies and procedures.

🏝️ Benefits

• Fully remote work-from-home option available.

• Up to 10% annual travel for team meetings or limited client engagements.

• Benefits information can be found at https://www.exlservice.com/us-careers-and-benefits.

• Competitive base salary based on a national hiring scale.

• Compensation may be higher in more expensive regions such as California, New York, and New Jersey.