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Core Competencies
Role fitCore Competencies
Use this summary to align your resume positioning with the role.
Demonstrates expertise in clinical reviews and billing accuracy for skilled nursing facilities, applying CMS guidelines and ICD-10 coding. Proficient in audit documentation and compliance with HIPAA and regulatory standards.
Highest-signal resume keywords
RN/LPN/LVN License3+ Years Skilled Nursing ExperienceRAC CertificationMDS Coordinator ExperienceProficiency in Excel, Word, and OneNote
ATS Keywords
Tailor your resumeApplicant Tracking System Keywords
Tip: use these terms in your resume and cover letter to boost ATS matches.
Hard Skills
Clinical ReviewICD-10 CodingAudit DocumentationBilling AccuracyReimbursement SystemsHIPPS CodingAudit Trend IdentificationWorkflow Process ManagementAttention to DetailAnalytical Skills
Soft Skills
Time ManagementWork PrioritizationWritten CommunicationVerbal Communication
Tools & Technologies
EXL ToolsProprietary Workflow Systems
Certifications & Qualifications
RAC Certification
Industry Keywords
CMS GuidelinesPDPMRUGMedicaid 48 GrouperSkilled Nursing Facility BillingComplianceFederal RegulationsState Regulations
About the role
Key responsibilities & impact- Conduct clinical reviews to verify the accuracy of skilled nursing facility billing
- Apply CMS clinical guidelines and payer-provider contract terms and policies to identify overpayments under PDPM, RUG, and contracted per diem methodologies
- Apply ICD-10 coding guidelines to validate diagnoses coded on Minimum Data Set assessments
- Document accurate audit results, audit rationales, and supporting findings using EXL tools, CMS guidelines, and payer contractual terms and policies
- Use proprietary workflow systems to make audit determinations and move claims through the workflow process
- Meet or exceed EXL program productivity and quality goals
- Monitor changes and updates to clinical guidelines, reimbursement trends, client processes, and requirements
- Comply with EXL policies and procedures, including HIPAA and state and federal regulations
- Identify audit trends and opportunities and write professional communications documenting findings
Requirements
What you’ll need- RN/LPN/LVN with current active license
- LPN or Registered Nurse with Associate's or Bachelor's degree preferred
- 3+ years of skilled nursing experience
- Preference for candidates with RAC certification, reimbursement experience, or MDS coordinator experience 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 billing HIPPS codes and days of billing for each assessment type
- Proficiency in Excel, Word, and OneNote with general computer literacy
- Ability to work independently in a remote environment during EXL core business hours
- Strong time management, work prioritization, written and verbal communication, analytical, and attention-to-detail skills
Benefits
Comp & perks- Up to 10% annual travel for team meetings and limited client onsite engagements
- More information on benefits and offerings is available at https://www.exlservice.com/us-careers-and-benefits