Outpatient Auditor III – Certified

Job Description:
• Apply 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.
• 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.
• 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.

Requirements:
• 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.

Benefits:
• Up to 10% annual travel (for team meetings and limited client onsite engagements.)
• 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.

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