Skilled Nursing Facilities Auditor III
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Job Description
Skilled Nursing Facilities Auditor III validating billing, coding, and reimbursement accuracy for EXL’s healthcare auditing services. Identifying overpayments, documenting findings, and applying CMS and payer requirements.
Responsibilities:
- Conduct clinical reviews to verify the accuracy of skilled nursing facility billing
- Apply CMS clinical guidelines and payer-provider contract terms and policies to identify overpayments under PDPM, RUG, and contracted per diem methodologies
- Apply ICD-10 coding guidelines to validate diagnoses coded on Minimum Data Set assessments
- Document accurate audit results, audit rationales, and supporting findings using EXL tools, CMS guidelines, and payer contractual terms and policies
- Use proprietary workflow systems to make audit determinations and move claims through the workflow process
- Meet or exceed EXL program productivity and quality goals
- Monitor changes and updates to clinical guidelines, reimbursement trends, client processes, and requirements
- Comply with EXL policies and procedures, including HIPAA and state and federal regulations
- Identify audit trends and opportunities and write professional communications documenting findings
Requirements:
- RN/LPN/LVN with current active license
- LPN or Registered Nurse with Associate's or Bachelor's degree preferred
- 3+ years of skilled nursing experience
- Preference for candidates with RAC certification, reimbursement experience, or MDS coordinator experience with knowledge of PDPM/RUG
- Previous experience/exposure to RUG and PDPM Medicare reimbursement systems and the Medicaid 48 grouper reimbursement system
- Previous experience/exposure to billing HIPPS codes and days of billing for each assessment type
- Proficiency in Excel, Word, and OneNote with general computer literacy
- Ability to work independently in a remote environment during EXL core business hours
- Strong time management, work prioritization, written and verbal communication, analytical, and attention-to-detail skills
Benefits:
- Up to 10% annual travel for team meetings and limited client onsite engagements
- More information on benefits and offerings is available at https://www.exlservice.com/us-careers-and-benefits
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