Resource Utilization Group Auditor III – Skilled Nursing Facility, SNF
EXL
Job Level
JuniorMid-Level
About the role
- Coordinate and oversee patient care plans in collaboration with physicians, therapists, and nursing staff
- Manage MDS (Minimum Data Set) assessments to ensure timely and accurate submission in accordance with federal and state regulations
- Review, monitor, and manage managed care authorizations, ensuring patients receive appropriate and approved services
- Participate in triple check processes to ensure accuracy of billing, coding, and clinical documentation
- Communicate regularly with insurance providers, patients, and families regarding care plans and coverage
- Monitor patient progress, outcomes, and transitions of care to reduce readmissions and optimize quality of care
- Maintain compliance with regulatory requirements, company policies, and professional standards
- Serve as a resource for staff education and training related to managed care, MDS, and documentation standards
- Assist with audits, reporting, and quality assurance initiatives
Requirements
- Current Licensed Practical Nurse (LPN) in good standing [State-specific license required]
- Minimum of 2+ years of experience in case management, utilization review, or related nursing role
- Hands-on experience with MDS assessments and knowledge of CMS guidelines
- Knowledge and prior experience in managed care processes and insurance authorizations
- Familiarity with triple check process for billing and reimbursement
- Strong organizational, communication, and problem-solving skills
- Ability to work independently and collaboratively in a fast-paced healthcare environment
- Proficient in electronic medical records (EMR) systems and Microsoft Office Suite
- Certification in Case Management (CCM or ACM) a plus, but not required
