High Cost Drug Auditor (HCD)

In this fully remote position as an HCD Auditor you will apply your expert knowledge of billing HCD claims to perform extensive audit reviews. You will utilize HCPCS codes, medical record review, industry and EXL proprietary tools in the audit process. Write professional communications documenting audit findings and supporting rationales. You will also apply your extensive industry knowledge to identify audit trends and opportunities.

• Conduct HCPCS coding reviews to verify the accuracy of the coding assignment and reimbursement on high cost drug professional and outpatient facility claims.
• Apply complex medical record reviews to identify discrepancies between physician orders, nursing administration logs, and final claims submissions.
• Apply Medicare, Medicaid, and commercial 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 AMA Guidelines.
• Utilize proprietary workflow systems to make audit determinations, generate audit rationales, and move claims through workflow process correctly efficiently and accurately.
• Accurately reprice complex claims utilizing multiple client claims systems.
• Meet or exceed EXL established program productivity and quality goals, including uphold rate for appeals.
• Research prescribed drug dosage and related conditions to ensure appropriateness of medical guidelines and accuracy of reimbursement.
• Comply with all EXL policies and procedures including HIPAA and other state and federal regulations.

Required Qualifications

• Three or more years' experience in claims processing or HCD medical billing experience with expert knowledge HCPCS codes.
• Experience reading and interpreting contract language and fee schedules and medical record review.
• Intermediate skills in Word and basic computer literacy.
• Intermediate skills in Excel including comfort working with charts, graphs, and percentages.
• Basic math skills with ability to do conversion calculations.
• High school diploma obtained

Preferred Qualifications

• Certified Pharmacy Technician or one or more of the following credentials: RHIA or CPC; preference given to those with multiple credentials.
• Expert in HCPCS codes with advanced knowledge of medical terminology.
• Experience with encoder tools and industry systems (FACETS, NASCO, Encoder Pro, TrueCode, 3M, Webstrat, Pricers).

Professional Qualifications

• 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.
• Enthusiastic about Auditing with a desire to work in an environment thriving on teamwork, excellence, collaboration, inclusiveness, and support.

Salary range $60,000.00-$90,000.00.

0-10% travel may be required.

For more information on benefits and what we offer please visit us at https://www.exlservice.com/us-careers-and-benefits