Clinical Validation Auditor III

Summary:

In this fully remote position as a Clinical Validation Auditor you will apply your expert clinical knowledge in the auditing of inpatient medical records to validate or revise the provider's billed DRG code. You will utilize industry and EXL proprietary tools in the DRG assignment 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 identify referrals for DRG coding review.

Responsibilities:

• Conduct MS-DRG and/or APR-DRG clinical reviews to verify the accuracy of the DRG assignment and reimbursement.
• Apply clinical guidelines to a variety of claim scenarios and effectively utilize industry and proprietary tools to maximize overpayment identifications.
• Document audit results in a clear, concise, and effective manner using clinical guidelines and ICD 10 CM/PCS coding rules and guidelines.
• Utilize proprietary workflow systems and encoder tools (e.g., 3M, Webstrat, etc.) 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, including uphold rate for appeals.
• 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:

• Registered Nurse, Associate's or Bachelor's degree
• 5+ years of acute care nursing experience with preference given to candidates with prior clinical or coding validation audit experience.
• Prefer candidate with prior DRG retrospective overpayment identification auditing experience.
• Prefer candidate with prior readmission (PPR) auditing experience.
• Preference given to candidates with CCS, RHIA, or RHIT coding credentials.

Knowledge, Skills, Behaviors:

• Extensive knowledge and understanding of clinical criteria documentation requirements used to successfully substantiate code assignments.
• Experience with DRG encoder tools (3M, Webstrat).
• Works independently in a remote environment and delivers exceptional results during EXL core business hours.
• Possesses excellent time management and work prioritization skills.
• Takes ownership of problem solving.
• 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 DRG Auditing with a desire to work in an environment thriving on teamwork, excellence, collaboration, inclusiveness, and support.

EEO/Minorities/Females/Vets/Disabilities