Outpatient Auditor III

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

📋 Description

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

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

• Review UB-04 facility claims to confirm the correctness of 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.

• Verify APC assignments for chemotherapy and non-chemotherapy infusions, hydration, and observation services.

• Analyze surgical encounters for appropriate APC selection based on procedure complexity and status indicators.

• Review interventional radiology encounters to ensure proper APC grouping and compliance with bundling regulations.

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

• Evaluate facility billing independently of 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 assess APC payment outcomes.

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

• Stay updated on APC revisions, OPPS rule changes, CMS transmittals, and payment indicator updates.

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

⛳️ Requirements

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

• A minimum of 3 years of experience in hospital outpatient facility coding and/or auditing, with direct involvement in APC-driven reimbursement.

• Proficient understanding of APC payment methodologies.

• In-depth knowledge of OPPS reimbursement logic.

• Familiarity with the impact of CPT/HCPCS coding on APC assignments.

• Knowledge of UB-04 facility billing requirements.

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

• Strong grasp of payer contracts, claims adjudication, and reimbursement variance analysis.

• Advanced experience in APC auditing, particularly with comprehensive and composite APC scenarios, is preferred.

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

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

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

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

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

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

🏝️ Benefits

• Opportunity to work remotely from home with limited travel requirements.

• Up to 10% annual travel for team meetings and occasional 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.

• Emphasis on work-life balance.

• Competitive base salary range of $70,000–$90,000, with the potential for compensation above this range in higher-cost regions.