Skilled Nursing Facility / Resource Utilization Group Auditor III, Healthcare
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Job Description
Auditing skilled nursing facility claims ensuring accuracy of billing in a fully remote role. Requires strong clinical knowledge and experience with Medicare reimbursement systems.
Responsibilities:
- Apply your expert clinical knowledge to validate the accuracy of billed charges to ensure the integrity of the paid claim.
- Conduct clinical reviews to verify the accuracy of skilled nursing facility billing.
- Apply CMS clinical guidelines and payer-provider contract terms and policies to a variety of claim scenarios to identify overpayments for claims paid under PDPM, RUG, and contracted per diem payment methodologies.
- Apply ICD-10 coding guidelines to validate diagnoses coded on Minimum Data Set assessment.
- Document accurate audit results in a clear, concise, and effective manner using applicable EXL tools, CMS guidelines, payer contractual terms and policies.
- Utilize proprietary workflow systems efficiently and accurately to make audit determinations, generate audit rationales and move claims through workflow process correctly.
- Meet or exceed EXL established program productivity and quality goals.
- Demonstrate knowledge of and compliance with changes and updates to clinical guidelines, reimbursement trends, and client processes and requirements.
- Comply with all EXL policies and procedures including HIPAA and other state and federal regulations.
Requirements:
- RN/LPN/LVN with current active license
- LPN, Registered Nurse with Associate's or Bachelor's degree preferred
- 3+ years of skilled nursing experience with preference given to candidates with RAC certification, reimbursement or MDS coordinator 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 the billing of HIPPS codes and days of billing for each assessment type.
- Excellent time management and work prioritization skills.
- Demonstrates excellent written and verbal communication skills, strong analytical skills, and attention to detail.
- Proficient in Excel, Word, and OneNote with general computer literacy.
- Passionate about auditing skilled nursing claims with a desire to work in an environment thriving on teamwork, excellence, collaboration, inclusiveness, and support.
- Works independently in a remote environment and delivers exceptional results during EXL core business hours.
- Takes ownership of problem solving.
Benefits:
- For more information on benefits and what we offer please visit us at https://www.exlservice.com/us-careers-and-benefits
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