Outpatient Auditor III

Are you an experienced Outpatient Facility Auditor with strong APC reimbursement expertise in hospital-based outpatient services? Do you enjoy analyzing APC groupings, status indicators, payment logic, and CMS OPPS compliance across infusion services, outpatient surgeries, and interventional radiology?

EXL Health is seeking a highly skilled auditor to join our growing remote outpatient auditing team, where your work will focus exclusively on facility‑based outpatient claims and APC reimbursement. This role is ideal for auditors who specialize in hospital outpatient facility coding and reimbursement.

As a Remote Certified Outpatient Facility Auditor, you will apply your 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.

 Salary Range: $70,000 – $90,000 (based on experience, skills, and qualifications)
 Location: 100% Remote (U.S.-based)

✈️ Up to 10% annual travel (for team meetings and limited client onsite engagements.)

A brief coding/auditing assessment may be included as part of the interview process

Responsibilities

• 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.
• Evaluate APC packaging rules, including bundled payment of:
  – Ancillary services
  – Supplies and minor procedures
  – Drug administration services packaged into primary procedures
• 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
• Validate proper billing of technical components, including nursing services, equipment usage, supplies, imaging contrast, and facility resources tied to APC reimbursement.
• Ensure facility billing is independent from professional claims, with APC reimbursement evaluated separately from physician payment.
• Apply CMS OPPS regulations, CPT rules, NCCI edits, and AHA Coding Clinic guidance to support compliant APC reimbursement.
• Identify overpayments, underpayments, misassigned APCs, inappropriate unbundling, and missed reimbursement opportunities.
• Utilize encoder and audit tools (3M, Webstrat, Optum Encoder) as well as EXL proprietary systems to analyze APC payment outcomes.
• Produce clear, defensible audit findings that articulate APC-related reimbursement impacts and compliance risks.
• Stay current on annual APC updates, OPPS rule changes, CMS transmittals, and payment indicator revisions.
• Meet or exceed EXL productivity, quality, and compliance standards.

Qualifications

Required

• 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.

What We Offer

Join a high-performing team at EXL Health, where APC expertise, audit precision, and regulatory compliance are actively valued.

• 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.

 Your APC expertise drives reimbursement accuracy and compliance.
Join EXL Health to strengthen outpatient reimbursement integrity and make a measurable impact across the healthcare industry.

 Apply today to begin your journey with EXL Health!

For more information on benefits and what we offer please visit us at https://www.exlservice.com/us-careers-and-benefits