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

EXL (NASDAQ: EXLS) is a leading data analytics and digital operations and solutions company. We partner with clients using a data and AI-led approach to reinvent business models, drive better business outcomes and unlock growth with speed. EXL harnesses the power of data, analytics, AI, and deep industry knowledge to transform operations for the world’s leading corporations in industries including insurance, healthcare, banking and financial services, media and retail, among others. EXL was founded in 1999 with the core values of innovation, collaboration, excellence, integrity and respect. We are headquartered in New York and have more than 54,000 employees spanning six continents. For more information, visit www.exlservice.com.

EXL never requires or asks for fees/payments or credit card or bank details during any phase of the recruitment or hiring process and has not authorized any agencies or partners to collect any fee or payment from prospective candidates. EXL will only extend a job offer after a candidate has gone through a formal interview process with members of EXL’s Human Resources team, as well as our hiring managers.

EXL is the indispensable partner for leading businesses in data-led industries such as insurance, banking and financial services, healthcare, retail and logistics. We bring a unique combination of data, advanced analytics, digital technology and industry expertise to help our clients turn data into insights, streamline operations, improve customer experience, and transform their business. Our partnerships with clients are built on a foundation of collaboration – and we’ve been chosen as a partner by nine of the top ten leading US insurance companies, nine of the top 20 global banks, and six of the top ten US health care payers. We function as one team to make your goals our goals, whether that’s unlocking the value of generative AI or embedding analytics into workflows that reduce risk or power your growth. Clients choose EXL as their transformation partner for many reasons. Our geographic diversity make talent all over the world instantly accessible. Digital accelerators enable unmatched speed-to-value, letting you realize results fast. It’s our people that truly set us apart, though, including the 1,500 data scientists we have dedicated to our generative AI practice. And our more than twenty years of experience in delivering business services, garnering stellar client references, and maintaining a solid balance sheet are reassuring to our C-suite clients. Find out for yourself why clients, employees, and analysts think we’re some of the best in the business. Contact us to see how we can help you achieve your goals.