Home Health Auditor III
EXL
Resource Utilization Group Auditor III – Skilled Nursing Facility, SNF
EXL
full-time
Posted on:
Origin: • 🇺🇸 United States
Visit company websiteJob Level
Mid-LevelSenior
About the role
- Apply expert clinical knowledge to validate accuracy of billed charges, including coding validation, payment accuracy, contractual requirements and regulatory compliance
- Utilize industry and EXL proprietary tools in the review process and write professional communications documenting audit findings and supporting rationales
- Conduct clinical reviews to verify the accuracy of skilled nursing facility billing
- Apply CMS clinical guidelines and payer-provider contract terms and policies to identify overpayments for claims paid under PDPM, RUG, and contracted per diem methodologies
- Apply ICD-10 coding guidelines to validate diagnoses coded on Minimum Data Set assessment
- Document accurate audit results using EXL tools, CMS guidelines, payer contractual terms and policies
- Utilize proprietary workflow systems to make audit determinations, generate audit rationales and move claims through workflow correctly
- Meet or exceed EXL established program productivity and quality goals
- Demonstrate knowledge of and compliance with changes and updates to clinical guidelines, reimbursement trends, and client processes and requirements
- Comply with all EXL policies and procedures including HIPAA and other state and federal regulations
- Identify audit trends and opportunities based on clinical and industry knowledge
Requirements
- RN/LPN/LVN with current active license
- LPN, Registered Nurse with Associate's or Bachelor's degree preferred
- 3+ years of skilled nursing experience with preference given to candidates with RAC certification, reimbursement or MDS coordinator with knowledge of PDPM/RUG
- Previous experience/exposure to RUG and PDPM Medicare reimbursement systems and the Medicaid 48 grouper reimbursement system
- Previous experience/exposure to the billing of HIPPS codes and days of billing for each assessment type
- Possesses excellent time management and work prioritization skills
- Demonstrates excellent written and verbal communication skills, strong analytical skills, and attention to detail
- Proficient in Excel, Word, and OneNote with general computer literacy
- Passionate about auditing skilled nursing claims and working in a team-oriented, collaborative environment
- Works independently in a remote environment and delivers exceptional results during EXL core business hours
- Takes ownership of problem solving
- Study level: Bachelor's Degree
