Clinical Readmission Review Auditor III

EXL • United States,

12h • $70,000 - $98,700 • Remote

About The Position

This role evaluates the clinical circumstances surrounding related inpatient admissions, the care delivered, discharge planning, and whether a subsequent admission may have been clinically related or potentially preventable. The position is fully remote within the United States and may require up to 10% annual travel for team meetings or limited client engagements. A brief coding/auditing assessment may be included as part of the interview process.

Requirements

• Active, unrestricted Registered Nurse (RN) license in the United States.
• At least four years of acute-care clinical nursing experience.
• Strong knowledge of inpatient care, disease progression, discharge planning, transitions of care, medical necessity, and factors contributing to readmissions.
• Ability to synthesize complex medical-record documentation and make objective, evidence-based clinical determinations.
• Strong written and verbal communication skills, including the ability to explain clinical findings clearly and professionally.
• Proficiency with Microsoft Excel, Word, and OneNote, along with strong overall computer literacy.
• Self-motivated and able to work independently in a remote setting while meeting quality and productivity expectations.

Nice To Haves

• Bachelor of Science in Nursing (BSN).
• Experience in inpatient case management, utilization review, clinical auditing, quality, or readmission review.

Responsibilities

• Conduct comprehensive clinical reviews of initial and subsequent inpatient admissions to evaluate the relationship between episodes of care.
• Review the complete medical record, including clinical presentation, diagnoses, treatment, response to treatment, discharge disposition, follow-up plan, and subsequent readmission.
• Assess whether the readmission was clinically related to the prior admission and whether opportunities existed to prevent or reduce the likelihood of readmission.
• Evaluate the medical necessity and clinical appropriateness of inpatient services using applicable clinical criteria, client requirements, and evidence-based standards.
• Identify concerns involving discharge readiness, continuity of care, follow-up services, medication management, or other clinical factors documented in the record.
• Prepare clear, concise, and well-supported clinical findings that accurately reflect the documentation reviewed and the rationale for the determination.
• Respond to provider disputes or appeals by completing an objective clinical reassessment and supporting the final determination with relevant medical-record evidence.
• Meet EXL quality, productivity, timeliness, and documentation standards while maintaining consistent and defensible review decisions.
• Maintain current knowledge of readmission review practices, clinical guidelines, utilization management principles, and applicable regulatory or client requirements.
• Protect confidential information and comply with HIPAA and EXL policies and procedures.

What This Job Offers

• Job Type: Full-time
• Career Level: Senior
• Education Level: No Education Listed