High Cost Drug Auditor III
EXL
full-time
Posted on:
Location Type: Remote
Location: United States
Visit company websiteExplore more
Salary
💰 $60,000 - $90,000 per year
About the role
- Apply your expert knowledge of billing HCD claims to perform extensive audit reviews.
- Utilize HCPCS codes, medical record review, industry and EXL proprietary tools in the audit process.
- Write professional communications documenting audit findings and supporting rationales.
- Apply your extensive industry knowledge to identify audit trends and opportunities.
- Conduct HCPCS coding reviews to verify the accuracy of the coding assignment and reimbursement on high cost drug professional and outpatient facility claims.
- Apply complex medical record reviews to identify discrepancies between physician orders, nursing administration logs, and final claims submissions.
- Apply Medicare, Medicaid, and commercial guidelines to a variety of claim scenarios and effectively utilize industry and proprietary tools to maximize overpayment identifications.
- Document audit results in a clear, concise, and effective manner using AMA Guidelines.
- Utilize proprietary workflow systems to make audit determinations, generate audit rationales, and move claims through workflow process correctly efficiently and accurately.
- Accurately reprice complex claims utilizing multiple client claims systems.
- Meet or exceed EXL established program productivity and quality goals, including uphold rate for appeals.
- Research prescribed drug dosage and related conditions to ensure appropriateness of medical guidelines and accuracy of reimbursement.
- Comply with all EXL policies and procedures including HIPAA and other state and federal regulations.
Requirements
- Three or more years' experience in claims processing or HCD medical billing experience with expert knowledge HCPCS codes.
- Experience reading and interpreting contract language and fee schedules and medical record review.
- Intermediate skills in Word and basic computer literacy.
- Intermediate skills in Excel including comfort working with charts, graphs, and percentages.
- Basic math skills with ability to do conversion calculations.
- High school diploma obtained
- Certified Pharmacy Technician or one or more of the following credentials: RHIA or CPC; preference given to those with multiple credentials.
- Expert in HCPCS codes with advanced knowledge of medical terminology.
- Experience with encoder tools and industry systems (FACETS, NASCO, Encoder Pro, TrueCode, 3M, Webstrat, Pricers).
Benefits
- 0-10% travel may be required.
- For more information on benefits and what we offer please visit us at https://www.exlservice.com/us-careers-and-benefits
Applicant Tracking System Keywords
Tip: use these terms in your resume and cover letter to boost ATS matches.
Hard Skills & Tools
HCD claims auditingHCPCS codingmedical record reviewclaims processingreimbursement accuracydata analysisconversion calculationsprofessional communicationaudit documentationclaim repricing
Soft Skills
attention to detailanalytical thinkingproblem-solvingorganizational skillseffective communicationtime managementteam collaborationadaptabilitycritical thinkingproductivity focus
Certifications
Certified Pharmacy TechnicianRHIACPC