Outpatient Auditor III

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

📋 Description

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

• Assess outpatient claims to ensure the correctness of CPT/HCPCS-to-APC mapping, which includes significant procedures, packaged, comprehensive, and composite APCs.

• Review UB-04 facility claims for the accurate application of CPT/HCPCS codes, modifiers, revenue codes, and charge structures.

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

• Perform audits on infusion therapy, outpatient surgical procedures, imaging, and interventional radiology encounters.

• Verify the billing of technical components such as nursing services, equipment, supplies, imaging contrast, and facility resources.

• Assess APC reimbursement distinctly from physician payments.

• Implement 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 outcomes.

• Generate defensible audit conclusions that outline reimbursement effects and compliance risks.

• Remain updated on APC modifications, OPPS rule amendments, 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 with APC-driven reimbursement.

• Proficient understanding of APC payment methodologies, OPPS reimbursement principles, the impact of CPT/HCPCS coding on APC assignments, and UB-04 facility billing standards.

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

• Strong knowledge of payer agreements, claims adjudication, and reimbursement variance analysis.

• Advanced experience in auditing intricate APC encounters, especially comprehensive and composite APC scenarios, is preferred.

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

• Experience in identifying retrospective overpayments related to APC misassignments or improper unbundling is preferred.

• Familiarity with 3M, Webstrat, Optum Encoder, or comparable tools is preferred.

• Capability to work autonomously in a high-volume remote audit setting is preferred.

• Excellent written, verbal, and analytical communication skills are preferred.

• Proficiency in Microsoft Excel, Word, OneNote, and relevant applications is preferred.

🏝️ Benefits

• Pay for Performance Bonus.

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

• Collaborative environment with seasoned outpatient and APC-focused auditors.

• Continuous professional development regarding APC and OPPS regulatory updates.

• Mentorship and opportunities for career advancement.

• Remote flexibility with limited travel requirements.