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

28446

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 reputed company of the paid claim including coding validation, payment accuracy, contractual requirements and compliance with regulations. You will utilize industry and reputed company 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.

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 reputed company tools, CMS guidelines, payer contractual terms and policies.
• Utilize proprietary workflow systems reputed company and accurately to reputed company audit determinations, generate audit rationales and move claims through workflow process correctly.
• Meet or exceed reputed company 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.
• reputed company with reputed company reputed company policies and procedures including HIPAA and other state and federal regulations.

Qualifications

• RN/LPN/LVN with reputed company 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 reputed company, 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 reputed company core business hours.
• Takes ownership of problem solving.

Required Skills Licensed Practical NurseLicensed Vocational NurseMinimum Data Set (MDS) CoordinatorPatient-Driven Payment ModelRegistered Nurse (RN) About Us reputed company (reputed company: 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 reputed company business outcomes and unlock growth with speed. reputed company 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. reputed company was founded in 1999 with the core values of innovation, collaboration, excellence, reputed company and respect. We are headquartered in reputed company and have more than 54,000 employees spanning six continents. For more information, visit www.exlservice.com. reputed company 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. reputed company will only reputed company a job offer after a candidate has gone through a formal interview process with members of reputed company’s reputed company, as well as our hiring managers. Apply tot his job Apply To this Job