Outpatient Auditor III

EXL•Jacksonville, FL

3d•$70,000 - $90,000•Remote

About The Position

EXL Health is seeking an experienced outpatient facility auditor to join its remote auditing team. The role focuses exclusively on hospital-based outpatient facility claims and APC reimbursement, applying expertise in CPT/HCPCS coding, APC payment methodologies, and outpatient regulatory requirements to audit UB-04 claims. The auditor ensures accurate APC assignment, appropriate packaging, and compliant facility billing across infusion services, outpatient surgeries, imaging, and interventional radiology. Facility reimbursement is evaluated separately from professional claims. The role is 100% remote within the U.S., with up to 10% annual travel for team meetings and limited client onsite engagements. The posted salary range is $70,000–$90,000, based on experience, skills, and qualifications. The position is eligible for a pay-for-performance bonus. A brief coding or auditing assessment may be included in the interview process. Final offers depend on factors including skills and experience, internal pay equity, work location, market conditions, and the scope and responsibilities of the role.

Requirements

Hold an active credential such as CCS, RHIA, RHIT, or CPC.
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 impact 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

Multiple coding credentials are strongly preferred.
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 when explaining APC payment logic.
Proficiency in Microsoft Excel, Word, OneNote, and related applications.

Responsibilities

Perform hospital outpatient facility audits focused on APC assignment, payment status indicators, revenue code alignment, and OPPS reimbursement logic.
Review outpatient claims for accurate CPT/HCPCS-to-APC mapping, including significant procedure, packaged-service, comprehensive APC, and composite APC assignments 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 surgery, imaging, and interventional radiology encounters, including chemotherapy and non-chemotherapy infusions, hydration, observation-related services, surgical APC selection, and applicable bundling rules.
Validate billing of technical components, including nursing services, equipment usage, 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.