Certified Outpatient Surgical Auditor III

Role Overview

• Audit outpatient claims with a focus on APC groupings, revenue codes, CPT bundling rules, and UB‑04 facility coding requirements.
• Ensure accurate documentation and coding of technical components such as nursing services, equipment use, and place of service.
• Verify that facility charges and resource utilization are coded correctly and independently from provider claims.
• Conduct detailed audits across infusion therapy, surgical services, interventional radiology, and other hospital outpatient service lines.
• Review CPT, APC, to validate correct reporting and reimbursement.
• Apply Medicare regulations, NCCI edits, CPT rules, and AHA Coding Clinic guidance to support compliance.
• Identify overpayments, coding discrepancies, and missed reimbursement opportunities.
• Utilize encoder tools (3M, Webstrat, Optum Encoder) and EXL proprietary platforms to analyze and process claims.
• Produce clear and concise audit findings aligned with official coding rules.
• Stay current on outpatient regulatory changes, reimbursement updates, and clinical practice trends across infusion, surgery, and radiology.
• Meet or exceed EXL productivity, quality, and compliance standards.

Requirements

• Active credential(s) such as:
• CCS
• RHIA
• RHIT
• CPC
• (Multiple credentials preferred)
• Minimum 3 years of outpatient hospital and professional coding/auditing experience, including infusion, surgical, and interventional radiology cases.
• Strong understanding of CPT coding, APC reimbursement methodologies, and official coding guidelines.
• Familiarity with payer contracts and claim adjudication processes.
• Experience auditing complex outpatient surgical and interventional radiology cases.
• Advanced knowledge of infusion and injection coding regulations.
• Background in retrospective overpayment identification for hospital and professional claims.
• Proficiency with encoder tools (3M, Webstrat, Optum).
• Ability to work independently in a remote environment and manage multiple priorities.
• Strong written, verbal, and analytical communication skills.
• Proficiency in Microsoft Excel, Word, OneNote, and general computer applications.

Benefits

• Collaborative environment: Work alongside world-class healthcare consultants and be a part of a supportive team that values your input.
• Career growth: Learn new skills and gain exposure to different aspects of business operations while working in a fast-paced and engaging environment.
• Mentoring program: Receive guidance from experienced mentors who will help you develop professionally and provide career insights.
• Professional development: We encourage continuous growth and provide opportunities for you to excel within EXL Health and beyond.
• Work-life balance: Enjoy the flexibility of a remote work-from-home position, with occasional travel to expand your professional network.