Outpatient Auditor III

EXL•Jacksonville, FL

16h•$70,000 - $90,000•Remote

About The Position

EXL Health is seeking an experienced outpatient facility auditor for its remote auditing team. The role focuses exclusively on hospital-based outpatient facility claims and APC reimbursement. The auditor reviews UB-04 facility claims, applying CPT/HCPCS coding knowledge, APC payment methodologies, and outpatient regulatory guidance to support accurate APC assignment, appropriate packaging, and compliant facility billing. The position covers infusion services, outpatient surgeries, imaging, and interventional radiology, and evaluates facility reimbursement separately from professional claims. The auditor identifies reimbursement and compliance issues, produces defensible audit findings, uses encoder and audit tools, and stays current with CMS OPPS regulations and annual APC updates. The position is 100% remote within the United States, with up to 10% annual travel for team meetings and limited client onsite engagements. The salary range is $70,000–$90,000, based on experience, skills, and qualifications, and the position is eligible for a pay-for-performance bonus. A coding/auditing assessment may be included in the interview process.

Requirements

Hold an active credential such as CCS, RHIA, RHIT, or CPC; multiple credentials are strongly preferred.
Have at least 3 years of hospital outpatient facility coding and/or auditing experience with direct exposure to APC-driven reimbursement.
Demonstrate expertise in APC payment methodologies, OPPS reimbursement logic, the effect of CPT/HCPCS coding on APC assignment, and UB-04 facility billing requirements.
Have hands-on experience auditing infusion services, outpatient surgeries, and interventional radiology, including APC packaging and bundling scenarios.
Have a strong understanding of payer contracts, claim adjudication, and reimbursement variance analysis.

Nice To Haves

Advanced experience auditing complex APC encounters, including comprehensive and composite APC scenarios.
In-depth knowledge of infusion and injection coding, including drug status indicators and packaged versus paid drugs.
Experience identifying retrospective overpayments tied to APC misassignment or improper unbundling.
Proficiency with 3M, Webstrat, Optum Encoder, or similar tools.
Ability to work independently in a high-volume remote audit environment.
Strong written, verbal, and analytical communication skills, especially in explaining APC payment logic.
Proficiency in Microsoft Excel, Word, OneNote, and related applications.

Responsibilities

Perform detailed hospital outpatient facility audits focused on APC assignment, payment status indicators, revenue code alignment, and OPPS reimbursement logic.
Review outpatient claims to validate CPT/HCPCS-to-APC mapping, including significant procedure APCs, packaged services, comprehensive APCs, and composite APCs where applicable.
Audit UB-04 facility claims for accurate CPT/HCPCS codes, modifiers, revenue codes, and charge structures affecting APC payment.
Evaluate APC packaging rules for ancillary services, supplies, minor procedures, and drug administration services packaged into primary procedures.
Audit infusion therapy, outpatient surgery, imaging, and interventional radiology encounters, including chemotherapy and non-chemotherapy infusions, hydration, observation-related services, surgical APC selection, and bundling compliance.
Validate billing of technical components such as nursing services, equipment, supplies, imaging contrast, and facility resources tied to APC reimbursement.
Evaluate facility billing independently from professional claims and assess APC reimbursement separately from physician payment.
Apply CMS OPPS regulations, CPT rules, NCCI edits, and AHA Coding Clinic guidance to support compliant APC reimbursement.
Identify overpayments, underpayments, misassigned APCs, inappropriate unbundling, and missed reimbursement opportunities.
Use encoder and audit tools, including 3M, Webstrat, Optum Encoder, and EXL proprietary systems, to analyze APC payment outcomes.
Produce clear, defensible audit findings explaining APC-related reimbursement impacts and compliance risks.
Stay current on annual APC updates, OPPS rule changes, CMS transmittals, and payment indicator revisions.
Meet or exceed EXL productivity, quality, and compliance standards.