Outpatient Auditor III

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

📋 Description

• Conduct thorough audits of hospital outpatient facilities focusing on APC assignment, payment status indicators, revenue code alignment, and OPPS reimbursement principles.

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

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

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

• Audit cases involving infusion therapy, outpatient surgeries, imaging, and interventional radiology encounters.

• Verify billing of technical components, which include nursing services, equipment, supplies, imaging contrast, and facility resources.

• Analyze facility billing separately from professional claims.

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

• Detect overpayments, underpayments, incorrectly assigned 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 effects and compliance risks.

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

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

⛳️ Requirements

• Current credentials such as CCS, RHIA, RHIT, or CPC.

• At least 3 years of experience in hospital outpatient facility coding and/or auditing, with a focus on APC-driven reimbursement.

• Proficient understanding of APC payment methodologies.

• In-depth knowledge of OPPS reimbursement logic.

• Strong expertise in the impact of CPT/HCPCS coding on APC assignment.

• Comprehensive knowledge of UB-04 facility billing requirements.

• Practical experience in auditing infusion services, outpatient surgeries, and interventional radiology, including APC packaging and bundling situations.

• Solid grasp of payer contracts, claim adjudication, and reimbursement variance analysis.

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

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

• Experience in identifying retrospective overpayments related to APC misassignment or improper unbundling.

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

• Ability to work independently in a high-volume remote audit setting.

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

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

• A brief assessment related to coding/auditing may be included in the interview process.

🏝️ Benefits

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

• Collaborative work environment.

• Continuous professional development opportunities.

• Mentorship and career advancement pathways.

• Remote work flexibility with limited travel requirements.