Apply in‑depth knowledge of CPT/HCPCS coding, APC payment methodologies, and outpatient regulatory guidelines to audit UB‑04 facility claims only, ensuring accurate APC assignment, proper packaging, and compliant facility billing.
Perform detailed hospital outpatient facility audits with a strong focus on APC assignment, payment status indicators, revenue code alignment, and OPPS reimbursement logic.
Review outpatient claims to validate correct CPT/HCPCS-to-APC mapping, including appropriate assignment of: – Significant procedure APCs vs. packaged services – Comprehensive APCs (C-APCs) – Composite APCs where applicable
Audit UB‑04 facility claims to ensure accurate reporting of CPT/HCPCS codes, modifiers, revenue codes, and charge structures that directly impact APC payment.
Conduct audits across infusion therapy, outpatient surgeries, imaging, and interventional radiology, such as: – Verifying correct APC assignment for chemotherapy and non-chemotherapy infusions, hydration services, and observation-related services – Reviewing outpatient surgical encounters to ensure correct APC selection based on procedure complexity and status indicators – Auditing interventional radiology encounters to confirm appropriate APC grouping and compliance with bundling rules.

Active credential(s) such as: o CCS o RHIA o RHIT o CPC (Multiple credentials strongly preferred)
Minimum 3 years of hospital outpatient facility coding and/or auditing experience, with direct exposure to APC-driven reimbursement.
Demonstrated expertise in: – APC payment methodologies – OPPS reimbursement logic – CPT/HCPCS coding impact on APC assignment – UB‑04 facility billing requirements
Hands-on experience auditing infusion services, outpatient surgeries, and interventional radiology, including APC packaging and bundling scenarios.
Strong understanding of payer contracts, claim adjudication, and reimbursement variance analysis.

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 vs. 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 in explaining APC payment logic.
Proficiency in Microsoft Excel, Word, OneNote, and related applications.

Up to 10% annual travel (for team meetings and limited client onsite engagements.)
Collaborative environment: Work with experienced outpatient and APC-focused auditors.
Ongoing professional development: Stay ahead of APC and OPPS regulatory changes.
Mentorship & career growth: Learn from senior auditors and advance your outpatient auditing career.
Work-life balance: Enjoy remote flexibility with limited travel.

Outpatient Auditor III – Certified

Key skills