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

• 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.

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

The posted base salary range is the hiring base salary range for this role. Final offers are based on several factors, including: the candidate's skills and experience, internal pay equity, work location, market conditions for the role, and the specific scope and responsibilities of the position.