Skilled Nursing Facility / Resource Utilization Group Auditor III, Healthcare

Role Overview

• 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