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 11/4/2026full-timeRemote • Florida • United StatesMid-LevelSenior💰 $70,000 - $90,000 per yearWebsite

Core Competencies

Role fit

Core Competencies

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Demonstrates expertise in hospital outpatient facility audits, focusing on APC assignment, OPPS reimbursement logic, and CPT/HCPCS coding. Proficient in utilizing auditing tools and maintaining compliance with CMS regulations while producing clear audit findings.

Highest-signal resume keywords

APC Payment MethodologiesOPPS Reimbursement LogicCPT/HCPCS CodingUB-04 Facility BillingInfusion Services Auditing

ATS Keywords

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Applicant Tracking System Keywords

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Hard Skills

APC AssignmentCPT/HCPCS CodingUB-04 Claims AuditingAPC Packaging RulesInfusion Therapy CodingRevenue Code AlignmentOverpayment IdentificationReimbursement Variance AnalysisCompliance Risk AssessmentAudit Findings Documentation

Soft Skills

Analytical CommunicationWritten CommunicationVerbal CommunicationIndependent WorkAttention to Detail

Tools & Technologies

3MWebstratOptum EncoderEXL Proprietary SystemsMicrosoft ExcelMicrosoft WordMicrosoft OneNote

Certifications & Qualifications

CCSRHIARHITCPC

Industry Keywords

Outpatient Facility AuditsAPC Driven ReimbursementCMS OPPS RegulationsNCCI EditsAHA Coding Clinic Guidance

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 APC reimbursement separately from physician payment
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
Expertise in OPPS reimbursement logic
Expertise in CPT/HCPCS coding impact on APC assignment
Expertise in 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
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

Benefits

Comp & perks

Pay for Performance Bonus
Up to 10% annual travel for team meetings and limited client onsite engagements
Collaborative environment
Ongoing professional development
Mentorship & career growth
Remote flexibility with limited travel