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.

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

• Review UB-04 facility claims for correctness in CPT/HCPCS codes, modifiers, revenue codes, and charging structures.

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

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

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

• Evaluate facility billing independently from professional claims.

• 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 assess APC payment outcomes.

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

• Remain updated on APC modifications, OPPS regulation changes, CMS transmittals, and payment indicator updates.

• 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, with direct exposure to APC-driven reimbursement.

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

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

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

• Advanced auditing experience with complex APC encounters, including comprehensive and composite APC situations is preferred.

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

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

• Proficiency with 3M, Webstrat, Optum Encoder, or similar auditing tools is preferred.

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

• Strong written, verbal, and analytical communication abilities are preferred.

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

• A brief coding/auditing assessment may be included during the interview process.

🏝️ Benefits

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

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

• Continuous professional development regarding APC and OPPS regulatory updates.

• Mentorship and opportunities for career advancement.

• Flexibility for remote work with limited travel requirements.