Skilled Nursing Facility (SNF) / Resource Utilization Group (RUG) Auditor III, Healthcare

In this fully remote position as a Skilled Nursing Facility auditor you will apply your expert clinical knowledge to validate the accuracy of billed charges to ensure the integrity of the paid claim including coding validation, payment accuracy, contractual requirements and compliance with regulations.  You will utilize industry and EXL proprietary tools in the review process, and will write professional communications documenting audit findings and supporting rationales. You will also apply your extensive clinical and industry knowledge to identify audit trends and opportunities.

• 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.
• 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.

Knowledge And Skills:

• Possesses 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.

EXL (NASDAQ: EXLS) is a leading data analytics and digital operations and solutions company. We partner with clients using a data and AI-led approach to reinvent business models, drive better business outcomes and unlock growth with speed. EXL harnesses the power of data, analytics, AI, and deep industry knowledge to transform operations for the world’s leading corporations in industries including insurance, healthcare, banking and financial services, media and retail, among others. EXL was founded in 1999 with the core values of innovation, collaboration, excellence, integrity and respect. We are headquartered in New York and have more than 54,000 employees spanning six continents. For more information, visit www.exlservice.com. EXL never requires or asks for fees/payments or credit card or bank details during any phase of the recruitment or hiring process and has not authorized any agencies or partners to collect any fee or payment from prospective candidates. EXL will only extend a job offer after a candidate has gone through a formal interview process with members of EXL’s Human Resources team, as well as our hiring managers.