Outpatient Auditor III

EXL

. Perform detailed hospital outpatient facility audits focused on APC assignment, payment status indicators, revenue code alignment, and OPPS reimbursement logic .

Posted 10/24/2026full-timeRemote • United StatesMid-LevelSenior💰 $70,000 - $90,000 per yearWebsite

About the role

Key responsibilities & impact

Perform detailed hospital outpatient facility audits focused on APC assignment, payment status indicators, revenue code alignment, and OPPS reimbursement logic
Review outpatient claims to validate CPT/HCPCS-to-APC mapping, including significant procedure, packaged, comprehensive, and composite APCs
Audit UB-04 facility claims for accurate CPT/HCPCS codes, modifiers, revenue codes, and charge structures
Evaluate APC packaging rules for ancillary services, supplies, minor procedures, and drug administration services
Audit infusion therapy, outpatient surgeries, imaging, and interventional radiology encounters
Validate billing of technical components including nursing services, equipment, supplies, imaging contrast, and facility resources
Evaluate facility billing independently from professional claims
Apply CMS OPPS regulations, CPT rules, NCCI edits, and AHA Coding Clinic guidance
Identify overpayments, underpayments, misassigned APCs, inappropriate unbundling, and missed reimbursement opportunities
Use 3M, Webstrat, Optum Encoder, and EXL proprietary systems to analyze APC payment outcomes
Produce clear, defensible audit findings describing reimbursement impacts and compliance risks
Stay current on APC updates, OPPS rule changes, CMS transmittals, and payment indicator revisions
Meet or exceed EXL productivity, quality, and compliance standards

Requirements

What you’ll need

Active credential(s) such as CCS, RHIA, RHIT, or CPC
Minimum 3 years of hospital outpatient facility coding and/or auditing experience with direct exposure to APC-driven reimbursement
Expertise in APC payment methodologies, OPPS reimbursement logic, CPT/HCPCS coding impact on APC assignment, and 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
Advanced experience auditing complex APC encounters, including comprehensive and composite APC scenarios preferred
In-depth knowledge of infusion and injection coding, including drug status indicators and packaged versus paid drugs preferred
Experience identifying retrospective overpayments tied to APC misassignment or improper unbundling preferred
Proficiency with 3M, Webstrat, Optum Encoder, or similar tools preferred
Ability to work independently in a high-volume remote audit environment preferred
Strong written, verbal, and analytical communication skills preferred
Proficiency in Microsoft Excel, Word, OneNote, and related applications preferred
A brief coding/auditing assessment may be included in the interview process

Benefits

Comp & perks

Up to 10% annual travel for team meetings and limited client onsite engagements
Collaborative environment with experienced outpatient and APC-focused auditors
Ongoing professional development on APC and OPPS regulatory changes
Mentorship and career growth opportunities
Remote flexibility with limited travel