Skilled Nursing Facilities (SNF) Auditor III
At a glance
Mid-level Audit & Controls role at Fa Ewjt Saasfaprod1. United States · full-time · $60,100–$98,700 base.
financeroles summary, based on the employer's posting.
What you'll do
- Review skilled nursing claims to check billed services, diagnoses, payment amounts and compliance with contracts and regulations
- Use CMS guidance and payer terms to find overpayments across PDPM, RUG and per diem claims
- Check MDS diagnoses against ICD-10 coding rules and document findings with clear supporting explanations
- Move claims through audit workflow tools accurately while meeting quality and productivity targets
- Track audit patterns and keep your reviews current as clinical guidance, reimbursement practices and client processes change
What you bring
- You hold an active RN, LPN or LVN license
- You have at least three years of skilled nursing experience
- You have worked with RUG or PDPM reimbursement and Medicaid 48 grouper claims
- You have handled HIPPS billing codes and billing days for different assessment types
Who this fits
This role suits a licensed nursing professional with skilled nursing reimbursement knowledge who can work independently and communicate audit decisions clearly. It is fully remote within the U.S., with up to ten percent annual travel for team meetings and limited client visits. You’ll need to work during EXL core business hours.
From the employer
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.
Salary Range: $60,100 – $98,700 (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
For more information on benefits and what we offer please visit us at https://www.exlservice.com/us-careers-and-benefits
- 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.
Required:
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.
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.
Audit & Controls work from LinkedIn, X, Reddit and Upwork, in one list.
Each morning you get everything that fits, strongest first.
Audit & Controls$60k+
Find me workBy the team behind financeroles.