Outpatient Auditor III

EXL • United States,

4d • $70,000 - $90,000 • Remote

About The Position

EXL Health is seeking an experienced outpatient facility auditor to join its remote auditing team. The position focuses exclusively on hospital-based outpatient facility claims and APC reimbursement, applying knowledge of CPT/HCPCS coding, APC payment methodologies, and outpatient regulatory guidelines to audit UB-04 claims for accurate APC assignment, appropriate packaging, and compliant facility billing. The role covers infusion services, outpatient surgeries, imaging, and interventional radiology, and evaluates facility reimbursement independently from professional claims.

The auditor identifies payment errors and opportunities, documents defensible findings, keeps current with CMS OPPS and APC changes, and meets EXL productivity, quality, and compliance standards. The role is 100% remote within the United States, with up to 10% annual travel for team meetings and limited client onsite engagements. A brief coding or auditing assessment may be included in the interview process.

Requirements

• An active credential such as CCS, RHIA, RHIT, or CPC; multiple credentials are strongly preferred.
• At least 3 years of hospital outpatient facility coding and/or auditing experience, with direct exposure to APC-driven reimbursement.
• Demonstrated expertise in APC payment methodologies, OPPS reimbursement logic, CPT/HCPCS coding impact on APC assignment, and UB-04 facility billing requirements.
• Hands-on experience auditing infusion services, outpatient surgeries, and interventional radiology, including APC packaging and bundling scenarios.
• 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 related 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, particularly in explaining APC payment logic.
• Proficiency in Microsoft Excel, Word, OneNote, and related applications.

Responsibilities

• Perform detailed hospital outpatient facility audits, focusing on APC assignment, payment status indicators, revenue code alignment, and OPPS reimbursement logic.
• 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 that affect APC payment.
• Evaluate APC packaging rules for ancillary services, supplies, minor procedures, and drug administration services packaged into primary procedures.
• Audit infusion therapy, outpatient surgeries, 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 usage, supplies, imaging contrast, and facility resources tied to APC reimbursement.
• Evaluate APC reimbursement separately from physician payment and ensure facility billing is independent from professional claims.
• Apply CMS OPPS regulations, CPT rules, NCCI edits, and AHA Coding Clinic guidance.
• 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.

Benefits

• Pay-for-performance bonus eligibility.
• Collaborative environment with experienced outpatient and APC-focused auditors.
• Ongoing professional development to stay current with APC and OPPS regulatory changes.
• Mentorship and career growth opportunities.
• Remote flexibility with limited travel.

What This Job Offers

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