Short Stay Inpatient Auditor III

In this fully remote position as a Short Stay Nurse auditor, you will apply your expert clinical knowledge in the auditing of hospital admission records to validate the correct level of care. 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.

• Conduct clinical reviews to verify the accuracy of inpatient and observation billing.
• Apply MCG and InterQual clinical guidelines to a variety of claim scenarios to maximize overpayment identifications.
• Document audit results in a clear, concise, and effective manner using applicable clinical guidelines.
• 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, 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.

• Required: Registered Nurse, Associate's or Bachelor's degree
• 5+ years of acute care nursing experience including use of MCG and/or InterQual clinical guidelines with preference given to candidates with prior utilization management experience.

Knowledge and Skills:

• Extensive knowledge and understanding of MCG and InterQual criteria to make determinations regarding appropriate level of care.
• Extensive experience with encoder tools (3M, Webstrat, Optum Encoder). 
• 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 Hospital Admission Auditing with a desire to work in an environment thriving on teamwork, excellence, collaboration, inclusiveness, and support.