Outpatient Auditor III

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

📋 Description

• Conduct comprehensive audits of hospital outpatient facilities, concentrating on APC assignments, payment status indicators, revenue code alignment, and OPPS reimbursement principles.

• Examine outpatient claims to ensure accurate mapping of CPT/HCPCS to APC, including significant procedures, packaged services, comprehensive, and composite APCs.

• Review UB-04 facility claims for precise CPT/HCPCS codes, modifiers, revenue codes, and charge structures.

• Assess APC packaging regulations for ancillary services, supplies, minor procedures, and drug administration services.

• Audit encounters related to infusion therapy, outpatient surgeries, imaging, and interventional radiology.

• Validate billing for technical components, including nursing services, equipment, supplies, imaging contrast, and facility resources.

• Analyze APC reimbursement independently from physician payments.

• Apply CMS OPPS regulations, CPT guidelines, NCCI edits, and AHA Coding Clinic recommendations.

• Detect overpayments, underpayments, misassigned APCs, inappropriate unbundling, and missed reimbursement opportunities.

• Utilize 3M, Webstrat, Optum Encoder, and EXL proprietary systems to evaluate APC payment results.

• Generate clear and defensible audit findings that outline reimbursement impacts and compliance risks.

• Remain updated on APC modifications, OPPS regulatory changes, CMS transmittals, and revisions to payment indicators.

• Achieve or surpass EXL's productivity, quality, and compliance benchmarks.

⛳️ Requirements

• Possession of active credentials such as CCS, RHIA, RHIT, or CPC.

• At least 3 years of experience in hospital outpatient facility coding and/or auditing, specifically related to APC-driven reimbursement.

• In-depth knowledge of APC payment methodologies.

• Proficient understanding of OPPS reimbursement logic.

• Expertise in the impact of CPT/HCPCS coding on APC assignments.

• Familiarity with UB-04 facility billing requirements.

• Practical experience in auditing infusion services, outpatient surgeries, and interventional radiology, particularly concerning APC packaging and bundling scenarios.

• Strong comprehension of payer contracts, claim adjudication processes, and reimbursement variance analysis.

• Advanced experience auditing complex APC encounters, including comprehensive and composite APC cases.

• Thorough knowledge of infusion and injection coding, including drug status indicators and the distinction between packaged and paid drugs.

• Experience in identifying retrospective overpayments associated with APC misassignment or improper unbundling.

• Proficiency in using 3M, Webstrat, Optum Encoder, or similar auditing tools.

• Capability to work independently in a fast-paced remote audit environment.

• Excellent written, verbal, and analytical communication skills, particularly in clarifying APC payment logic.

• Proficiency in Microsoft Excel, Word, OneNote, and other related applications.

🏝️ Benefits

• Pay for Performance Bonus.

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

• Collaborative work atmosphere.

• Ongoing opportunities for professional development.

• Mentorship and career advancement.

• Remote flexibility with minimal travel requirements.