Skilled Nursing Facility (SNF) / Resource Utilization Group (RUG) Auditor III, Healthcare

Job Description: In this fully remote position as a Skilled Nursing Facility auditor you will apply your expert clinical knowledge to validate the accuracy of billed charges to ensure the integrity of the paid claim including coding validation, payment accuracy, contractual requirements and compliance with regulations. You will utilize industry and EXL proprietary tools in the review process, and will write professional communications documenting audit findings and supporting rationales. You will also apply your extensive clinical and industry knowledge to identify audit trends and opportunities. A brief coding/auditing assessment may be included as part of the interview process Salary Range for this role is $70,000 - $80,000 With 10% or less travel. For more information on benefits and what we offer please visit us at https://www.exlservice.com/us-careers-and-benefits The posted range is the hiring range for this role — a subset of the broader range available to employees over time — and reflects base salary across our national hiring scale. 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. The top of the range is reserved for candidates who notably exceed the requirements; the lower end applies to those with less experience or fewer preferred qualifications. For positions based in higher-cost zones (e.g., California, New York, New Jersey), actual compensation may exceed the posted range; your recruiter will share specifics during the process.

• Responsibilities: Conduct clinical reviews to verify the accuracy of skilled nursing facility billing.
• Apply CMS clinical guidelines and payer-provider contract terms and policies to a variety of claim scenarios to identify overpayments for claims paid under PDPM, RUG, and contracted per diem payment methodologies.
• Apply ICD-10 coding guidelines to validate diagnoses coded on Minimum Data Set assessment.
• Document accurate audit results in a clear, concise, and effective manner using applicable EXL tools, CMS guidelines, payer contractual terms and policies.
• Utilize proprietary workflow systems efficiently and accurately to make audit determinations, generate audit rationales and move claims through workflow process correctly.
• Meet or exceed EXL established program productivity and quality goals.
• Demonstrate knowledge of and compliance with changes and updates to clinical guidelines, reimbursement trends, and client processes and requirements.
• Comply with all EXL policies and procedures including HIPAA and other state and federal regulations.
• Qualifications: RN/LPN/LVN with current active license
• LPN, Registered Nurse with Associate's or Bachelor's degree preferred
• 3+ years of skilled nursing experience with preference given to candidates with RAC certification, reimbursement or MDS coordinator 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 the billing of HIPPS codes and days of billing for each assessment type.

Knowledge and Skills:

• Possesses excellent time management and work prioritization skills.
• Demonstrates excellent written and verbal communication skills, strong analytical skills, and attention to detail.
• Proficient in Excel, Word, and OneNote with general computer literacy.
• Passionate about auditing skilled nursing claims with a desire to work in an environment thriving on teamwork, excellence, collaboration, inclusiveness, and support.
• Works independently in a remote environment and delivers exceptional results during EXL core business hours.
• Takes ownership of problem solving.